Healthcare Provider Details

I. General information

NPI: 1174198014
Provider Name (Legal Business Name): NOEMI MAYORGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 W RAMSEY ST
BANNING CA
92220-4478
US

IV. Provider business mailing address

1069 LIVERPOOL LN
SAN JACINTO CA
92583-2668
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-8614
  • Fax: 951-849-2057
Mailing address:
  • Phone: 951-216-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: