Provider Demographics
NPI:1336998053
Name:VAZQUEZ, EMMANUEL (PT)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12871 HICKORY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3426
Mailing Address - Country:US
Mailing Address - Phone:619-717-9182
Mailing Address - Fax:
Practice Address - Street 1:14221 EUCLID ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4991
Practice Address - Country:US
Practice Address - Phone:714-891-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist