Provider Demographics
NPI:1902169451
Name:VASQUEZ, MARCO VINICIO
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:VINICIO
Last Name:VASQUEZ
Suffix:
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 1:15262 RIVER ROCK DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5344
Mailing Address - Country:US
Mailing Address - Phone:909-689-5065
Mailing Address - Fax:
Practice Address - Street 1:15262 RIVER ROCK DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-689-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA951991133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered