Basic Information
| Provider Information | |||||||||
| NPI: | 1366903239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMERO | ||||||||
| FirstName: | MAREL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9360 NO NAME UNO #130 | ||||||||
| Address2: | |||||||||
| City: | GILROY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088439350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9360 NO NAME UNO #130 | ||||||||
| Address2: | |||||||||
| City: | GILROY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088439350 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2019 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/08/2020 | ||||||||
| NPIReactivationDate: | 03/18/2020 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106S00000X | Y |
No ID Information.