Healthcare Provider Details

I. General information

NPI: 1760662605
Provider Name (Legal Business Name): ALEXIS A MARANTOS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 BLAINE ST SUITE B
RIVERSIDE CA
92507
US

IV. Provider business mailing address

769 BLAINE ST SUITE B
RIVERSIDE CA
92507-3379
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax: 951-358-4719
Mailing address:
  • Phone: 951-358-4705
  • Fax: 951-358-4719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number227150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: