Healthcare Provider Details

I. General information

NPI: 1851624571
Provider Name (Legal Business Name): LILLIAN GRAY MGONJA REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LILLIAN JOHN MMARI RN

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S. LONG BEACH BLVD SUITE A/B
COMPTON CA
90221
US

IV. Provider business mailing address

623 S. LONG BEACH BLVD SUITE A & B
LONG BEACH CA
90221
US

V. Phone/Fax

Practice location:
  • Phone: 310-637-0341
  • Fax: 310-637-0341
Mailing address:
  • Phone: 562-233-7970
  • Fax: 562-283-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number581333
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number581433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: