Healthcare Provider Details

I. General information

NPI: 1528788825
Provider Name (Legal Business Name): MIREYA ONTIVEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 CLARENDON AVE
HUNTINGTON PARK CA
90255-4119
US

IV. Provider business mailing address

2629 CLARENDON AVE
HUNTINGTON PARK CA
90255-4119
US

V. Phone/Fax

Practice location:
  • Phone: 323-584-3700
  • Fax:
Mailing address:
  • Phone: 323-584-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: