Healthcare Provider Details

I. General information

NPI: 1780135897
Provider Name (Legal Business Name): HEATHER NICHOL MAGLOTHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 BASELINE RD BOX 400
LA VERNE CA
91750-2353
US

IV. Provider business mailing address

233 BASELINE RD BOX 400
LA VERNE CA
91750-2353
US

V. Phone/Fax

Practice location:
  • Phone: 909-833-2986
  • Fax: 909-833-2998
Mailing address:
  • Phone: 909-833-2986
  • Fax: 909-833-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: