MEDICARE: MICHAEL RAE PEREZ

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	374K00000X	Religious Nonmedical Practitioner		CA

General Provider Information

NPI Number	:	1598457780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL RAE PEREZ

Provider Business Mailing Address
First Line	:	6288 GOLDEN TRAILS AVE
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9109
Country	:	US
Telephone Number	:	909-916-0593
Fax Number	:	909-542-3176

Provider Business Practice Location Address
First Line	:	350 S MILLIKEN AVE STE L
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-7846
Country	:	US
Telephone Number	:	909-916-0593
Fax Number	:

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

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	05/24/2023

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