Healthcare Provider Details

I. General information

NPI: 1235208489
Provider Name (Legal Business Name): ERIC LAWAYNE MAYES SR. INDEPENDENT DUTY HM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30394 SIERRA MADRE DR
TEMECULA CA
92591-7306
US

IV. Provider business mailing address

30394 SIERRA MADRE DR
TEMECULA CA
92591-7306
US

V. Phone/Fax

Practice location:
  • Phone: 951-972-4360
  • Fax:
Mailing address:
  • Phone: 971-952-4360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: