Healthcare Provider Details

I. General information

NPI: 1700254307
Provider Name (Legal Business Name): JAVIER MAYORGA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2015
Last Update Date: 09/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

2128 GLENROSE AVE
ALTADENA CA
91001-5528
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax:
Mailing address:
  • Phone: 626-253-2767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number277784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: