Provider Demographics
NPI:1386080356
Name:LIAO, VIVIAN PETRA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:PETRA
Last Name:LIAO
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 1:3460 E LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-2020
Mailing Address - Country:US
Mailing Address - Phone:916-734-7041
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131922208100000X, 2083X0100X
261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine