Healthcare Provider Details

I. General information

NPI: 1831986173
Provider Name (Legal Business Name): MIA URENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

578 WASHINGTON BLVD STE 913
MARINA DEL REY CA
90292-5421
US

IV. Provider business mailing address

578 WASHINGTON BLVD STE 913
MARINA DEL REY CA
90292-5421
US

V. Phone/Fax

Practice location:
  • Phone: 424-272-5238
  • Fax:
Mailing address:
  • Phone: 424-272-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: