Healthcare Provider Details

I. General information

NPI: 1871325944
Provider Name (Legal Business Name): MICHAEL MAYORGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5628 E SLAUSON AVE
COMMERCE CA
90040-2922
US

IV. Provider business mailing address

1821 1/2 S SYCAMORE AVE
LOS ANGELES CA
90019-5340
US

V. Phone/Fax

Practice location:
  • Phone: 323-318-9960
  • Fax:
Mailing address:
  • Phone: 310-266-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: