Healthcare Provider Details

I. General information

NPI: 1184183287
Provider Name (Legal Business Name): MIRIAM MIJARES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N CITRUS AVE STE A1
COVINA CA
91723-2060
US

IV. Provider business mailing address

7226 SEPULVEDA BLVD
VAN NUYS CA
91405-2003
US

V. Phone/Fax

Practice location:
  • Phone: 626-414-2228
  • Fax:
Mailing address:
  • Phone: 818-235-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: