Basic Information
| Provider Information | |||||||||
| NPI: | 1285084848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTORENA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | SELENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASTORENA AYON | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | SELENE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 S. SANTA ANITA AVE. | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | 6262941079 | ||||||||
| Practice Location | |||||||||
| Address1: | 13001 RAMONA BLVD | ||||||||
| Address2: | STE I | ||||||||
| City: | IRWINDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917063752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263373828 | ||||||||
| FaxNumber: | 6269604163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2016 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.