Healthcare Provider Details

I. General information

NPI: 1942808811
Provider Name (Legal Business Name): NELSON JAVIER MARAVILLA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

65792 ESTRELLA AVE
DESERT HOT SPRINGS CA
92240-3514
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone: 760-880-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: