Healthcare Provider Details

I. General information

NPI: 1164934592
Provider Name (Legal Business Name): MARIO D MIJARES CCS ADC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 AVENIDA ANDANTE
OCEANSIDE CA
92056-6908
US

IV. Provider business mailing address

1648 AVENIDA ANDANTE
OCEANSIDE CA
92056-6908
US

V. Phone/Fax

Practice location:
  • Phone: 808-721-9634
  • Fax:
Mailing address:
  • Phone: 808-721-9634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0346
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: