Provider Demographics
NPI:1801486709
Name:VIVANCO, REFUJIO JR
Entity type:Individual
Prefix:
First Name:REFUJIO
Middle Name:
Last Name:VIVANCO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-2960
Mailing Address - Country:US
Mailing Address - Phone:951-791-3300
Mailing Address - Fax:
Practice Address - Street 1:650 N STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-2960
Practice Address - Country:US
Practice Address - Phone:951-791-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty