Provider Demographics
NPI:1194103960
Name:ENVISION PERSONALIZED HEALTH
Entity type:Organization
Organization Name:ENVISION PERSONALIZED HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-229-9695
Mailing Address - Street 1:4620 ALVARADO CANYON RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4320
Mailing Address - Country:US
Mailing Address - Phone:619-229-9695
Mailing Address - Fax:619-229-9666
Practice Address - Street 1:4620 ALVARADO CANYON RD
Practice Address - Street 2:SUITE 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4320
Practice Address - Country:US
Practice Address - Phone:619-229-9695
Practice Address - Fax:619-229-9666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15489171100000X
CA13823171100000X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty