Basic Information
| Provider Information | |||||||||
| NPI: | 1477730570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASCORRO | ||||||||
| FirstName: | RAQUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E CREIGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468032471 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5535 S WILLIAMSON BLVD | ||||||||
| Address2: | SUITE 774 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003307711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 32001513A | IN | Y | Other Service Providers | Specialist |
No ID Information.