Basic Information
Provider Information | |||||||||
NPI: | 1952642415 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARYVALE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7600 E. GRAVES AVE | ||||||||
Address2: |   | ||||||||
City: | ROSEMEAD | ||||||||
State: | CA | ||||||||
PostalCode: | 917703414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262806510 | ||||||||
FaxNumber: | 6262881026 | ||||||||
Practice Location | |||||||||
Address1: | 7600 E. GRAVES AVE | ||||||||
Address2: |   | ||||||||
City: | ROSEMEAD | ||||||||
State: | CA | ||||||||
PostalCode: | 917703414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262806510 | ||||||||
FaxNumber: | 6262881026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2013 | ||||||||
LastUpdateDate: | 03/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | LICENSED PSYCHIATRIC TECHNICIAN | ||||||||
AuthorizedOfficialTelephone: | 6262806510 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | PT35715 | CA | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
No ID Information.