Basic Information
| Provider Information | |||||||||
| NPI: | 1861425696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | NEIL | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54701 FILE NUMBER | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Practice Location | |||||||||
| Address1: | 11406 LOMA LINDA DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095586277 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC7124 | CA | Y | Other Service Providers | Acupuncturist |
ID Information
| ID | Type | State | Issuer | Description | AC0071240 | 05 | CA | MEDICAID |