Provider Demographics
NPI:1124632476
Name:VASILCHENKO, ELVIRA
Entity type:Individual
Prefix:
First Name:ELVIRA
Middle Name:
Last Name:VASILCHENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1048
Mailing Address - Country:US
Mailing Address - Phone:619-354-0455
Mailing Address - Fax:
Practice Address - Street 1:10951 SORRENTO VALLEY RD STE 1D
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1613
Practice Address - Country:US
Practice Address - Phone:619-598-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78334405300000X
CACA18586171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18586Medicaid
CACA18586OtherLICENSE