Healthcare Provider Details

I. General information

NPI: 1427796515
Provider Name (Legal Business Name): MARIO JOSE MIRANDA CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CENTERPOINTE DR STE 700
LA PALMA CA
90623-2545
US

IV. Provider business mailing address

6 CENTERPOINTE DR STE 700
LA PALMA CA
90623-2545
US

V. Phone/Fax

Practice location:
  • Phone: 800-939-3410
  • Fax:
Mailing address:
  • Phone: 800-939-3410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: