Provider Demographics
NPI:1689473878
Name:WELLCARE VALLEY MEDICAL GROUP INC
Entity type:Organization
Organization Name:WELLCARE VALLEY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LACUESTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-370-6986
Mailing Address - Street 1:10324 BALBOA BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-7349
Mailing Address - Country:US
Mailing Address - Phone:747-370-6986
Mailing Address - Fax:
Practice Address - Street 1:10324 BALBOA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-7349
Practice Address - Country:US
Practice Address - Phone:949-324-8363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty