Healthcare Provider Details

I. General information

NPI: 1689391047
Provider Name (Legal Business Name): MADISON DIANE MALTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28643 VISTA MADERA
RANCHO PALOS VERDES CA
90275-0869
US

IV. Provider business mailing address

23842 HAWTHORNE BLVD STE 100-101
TORRANCE CA
90505-5929
US

V. Phone/Fax

Practice location:
  • Phone: 310-292-7923
  • Fax:
Mailing address:
  • Phone: 310-292-7923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: