Basic Information
| Provider Information | |||||||||
| NPI: | 1487000741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIAS | ||||||||
| FirstName: | EDNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MACIAS | ||||||||
| OtherFirstName: | EDNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | 6263019770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | 6263019770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2016 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.