Basic Information
| Provider Information | |||||||||
| NPI: | 1316210826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURTADO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ISABEL | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 952 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917661425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099978384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E HOLT AVE STE B | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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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 | 167G00000X | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.