Basic Information
| Provider Information | |||||||||
| NPI: | 1992448153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTEGA | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ORTEGA | ||||||||
| OtherFirstName: | MARINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RBT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12303 E 104TH PL UNIT 105 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800222098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206171574 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12303 E 104TH PL UNIT 105 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800222098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206171574 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2022 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.