Healthcare Provider Details

I. General information

NPI: 1376151217
Provider Name (Legal Business Name): MR. MARCO DIMAILIG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 S BERENDO ST APT 404
LOS ANGELES CA
90005-1749
US

IV. Provider business mailing address

624 S BERENDO ST APT 404
LOS ANGELES CA
90005-1749
US

V. Phone/Fax

Practice location:
  • Phone: 818-648-2170
  • Fax:
Mailing address:
  • Phone: 818-648-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberCPT00049914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: