Healthcare Provider Details

I. General information

NPI: 1912857012
Provider Name (Legal Business Name): MARIAH LARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2026
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY DR
ORANGE CA
92866-1005
US

IV. Provider business mailing address

901 E SOUTH ST
ANAHEIM CA
92805-5460
US

V. Phone/Fax

Practice location:
  • Phone: 714-628-7234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: