Provider Demographics
NPI:1770755225
Name:VICKERS, IZUMI
Entity type:Individual
Prefix:
First Name:IZUMI
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IZUMI
Other - Middle Name:
Other - Last Name:MURASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16940 HIGHWAY 14
Mailing Address - Street 2:SUITE F
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1238
Mailing Address - Country:US
Mailing Address - Phone:661-824-5020
Mailing Address - Fax:
Practice Address - Street 1:16940 HIGHWAY 14
Practice Address - Street 2:SUITE F
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1238
Practice Address - Country:US
Practice Address - Phone:661-824-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator