Healthcare Provider Details

I. General information

NPI: 1891472601
Provider Name (Legal Business Name): MAEDA FELICIANO CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SKYWAY DR
CAMARILLO CA
93010-8552
US

IV. Provider business mailing address

5535 CARLTON WAY APT 312
LOS ANGELES CA
90028-6833
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-1155
  • Fax: 805-383-1134
Mailing address:
  • Phone: 757-532-8874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number84677
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: