Healthcare Provider Details

I. General information

NPI: 1417867904
Provider Name (Legal Business Name): MARILYN LETICIA MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 E AIRPORT DR STE 112
SAN BERNARDINO CA
92408-3408
US

IV. Provider business mailing address

1699 E WASHINGTON ST APT 1045
COLTON CA
92324-4655
US

V. Phone/Fax

Practice location:
  • Phone: 909-698-8177
  • Fax:
Mailing address:
  • Phone: 909-698-8177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number85324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: