Basic Information
| Provider Information | |||||||||
| NPI: | 1821616616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARISCAL | ||||||||
| FirstName: | MAYRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15186 PERRIS BLVD APT 207 | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925514599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513554054 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3125 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.