Provider Demographics
NPI:1023825460
Name:LUCERO VASQUEZ, MARTHA AURORA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:AURORA
Last Name:LUCERO VASQUEZ
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 1:74800 SHERYL AVE
Mailing Address - Street 2:APT 92
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260
Mailing Address - Country:US
Mailing Address - Phone:760-979-8817
Mailing Address - Fax:
Practice Address - Street 1:73600 ALESSANDRO DRIVE
Practice Address - Street 2:SUITE 123
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-979-8817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79753225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist