Healthcare Provider Details

I. General information

NPI: 1912491895
Provider Name (Legal Business Name): MARIANELLA MIJARES CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 HEARTHSTONE DR
RIDGELAND SC
29936-7088
US

IV. Provider business mailing address

PO BOX 1460
HARDEEVILLE SC
29927-1460
US

V. Phone/Fax

Practice location:
  • Phone: 352-397-7450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number180808
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: