Basic Information
| Provider Information | |||||||||
| NPI: | 1396284980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAZQUEZ SOLIS | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | PAMELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 S. SEPULVEDA BLVD. | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 E. COLORADO STREET | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182447257 | ||||||||
| FaxNumber: | 8182435431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2017 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.