Healthcare Provider Details

I. General information

NPI: 1609501436
Provider Name (Legal Business Name): MAVERICK NEUROLOGICAL HEALTHCARE GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 VANTIS DR STE 300
ALISO VIEJO CA
92656-2677
US

IV. Provider business mailing address

120 VANTIS DR STE 300
ALISO VIEJO CA
92656-2677
US

V. Phone/Fax

Practice location:
  • Phone: 949-216-5185
  • Fax: 949-299-2715
Mailing address:
  • Phone: 949-216-5185
  • Fax: 949-299-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON SURETTE JOHNSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 949-216-5185