Healthcare Provider Details

I. General information

NPI: 1780176875
Provider Name (Legal Business Name): MIRIAM JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRIAM MARTINEZ

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 RIVERVIEW DR
JURUPA VALLEY CA
92509-6611
US

IV. Provider business mailing address

2252 PRESCOTT CIR
CORONA CA
92881-7463
US

V. Phone/Fax

Practice location:
  • Phone: 951-360-4175
  • Fax:
Mailing address:
  • Phone: 714-673-7990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: