Healthcare Provider Details

I. General information

NPI: 1962872085
Provider Name (Legal Business Name): MIGUEL MARIONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 W BEVERLY BLVD
MONTEBELLO CA
90640-1537
US

IV. Provider business mailing address

1839 W 20TH ST
LOS ANGELES CA
90007-1123
US

V. Phone/Fax

Practice location:
  • Phone: 323-453-7750
  • Fax: 323-722-4450
Mailing address:
  • Phone: 323-453-7750
  • Fax: 323-722-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: