Healthcare Provider Details

I. General information

NPI: 1336390111
Provider Name (Legal Business Name): MARISA SUZANNA MIJARES LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 CASS ST SUITE 112
MONTEREY CA
93940-4518
US

IV. Provider business mailing address

1011 CASS ST SUITE 112
MONTEREY CA
93940-4518
US

V. Phone/Fax

Practice location:
  • Phone: 831-402-6157
  • Fax:
Mailing address:
  • Phone: 831-402-6157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number11416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: