MEDICARE: MARIVIC GAY LUSTRE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	669067	CA

General Provider Information

NPI Number	:	1205207297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIVIC GAY LUSTRE

Provider Business Mailing Address
First Line	:	3049 CANYON VISTA DR
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-9791
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3049 CANYON VISTA DR
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-9791
Country	:	US
Telephone Number	:	909-465-3973
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2015
Last Update Date	:	10/15/2015

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