1578709739 NPI number — CLARISSA RENEE VARGAS RDH

Table of content: CLARISSA RENEE VARGAS RDH (NPI 1578709739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578709739 NPI number — CLARISSA RENEE VARGAS RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARGAS
Provider First Name:
CLARISSA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578709739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37468 CYPRESS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURNEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96013-4067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-335-3651
Provider Business Mailing Address Fax Number:
530-335-3221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36977 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96013-4067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-335-3651
Provider Business Practice Location Address Fax Number:
530-335-3221
Provider Enumeration Date:
12/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  RDH23967 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0RDH23967 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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