Basic Information
| Provider Information | |||||||||
| NPI: | 1548527013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAXIOLA | ||||||||
| FirstName: | REBECA | ||||||||
| MiddleName: | EDITH | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12785 FREDERICK ST | ||||||||
| Address2: | APT 206 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925534503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093295564 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13800 HEACOCK ST | ||||||||
| Address2: | SUITE C236 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925533339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516530819 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2012 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.