Basic Information
| Provider Information | |||||||||
| NPI: | 1255961124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELEZ | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PRECISION PARK LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921731345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192056349 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3025 BEYER BLVD STE E-101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921543432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2020 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.