Healthcare Provider Details

I. General information

NPI: 1760770663
Provider Name (Legal Business Name): MARIA SANJUANA OLMOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST STE B
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

24871 ROCK SPRINGS TRL
MORENO VALLEY CA
92557-5623
US

V. Phone/Fax

Practice location:
  • Phone: 909-358-4881
  • Fax:
Mailing address:
  • Phone: 909-659-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: