Healthcare Provider Details

I. General information

NPI: 1649346495
Provider Name (Legal Business Name): MARY STAHOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 CHICAGO AVE STE J3 U.S. HEALTHWORKS, RIVERSIDE FACILITY #345
RIVERSIDE CA
92507-2358
US

IV. Provider business mailing address

1760 CHICAGO AVE STE J3 U.S. HEALTHWORKS, RIVERSIDE FACILITY #345
RIVERSIDE CA
92507-2358
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-2200
  • Fax: 951-781-2220
Mailing address:
  • Phone: 951-781-2200
  • Fax: 951-781-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: