Healthcare Provider Details

I. General information

NPI: 1780257634
Provider Name (Legal Business Name): AILEEN MIQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 N WESTON PL
HEMET CA
92543-3006
US

IV. Provider business mailing address

7917 TAPIA ST
FONTANA CA
92336-3816
US

V. Phone/Fax

Practice location:
  • Phone: 951-791-4199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: