Healthcare Provider Details

I. General information

NPI: 1912029562
Provider Name (Legal Business Name): CAMILA AURELIA MARISCAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W LA CADENA DR
RIVERSIDE CA
92501-1413
US

IV. Provider business mailing address

841 N PEPPER AVE
RIALTO CA
92376-4526
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-8010
  • Fax:
Mailing address:
  • Phone: 909-875-0830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 128951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: