Basic Information
| Provider Information | |||||||||
| NPI: | 1831489681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYVALE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2502 E HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263571514 | ||||||||
| FaxNumber: | 6263594285 | ||||||||
| Practice Location | |||||||||
| Address1: | 2502 E HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263571514 | ||||||||
| FaxNumber: | 6263594285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | CULVER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF COMMUNITY BASED | ||||||||
| AuthorizedOfficialTelephone: | 6262639133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.