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General NPI Number Information
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NPI Number | 1194870808
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Entity Type | Individual
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Provider Name | JESSE MARAVILLA
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Gender | Male
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 13341 GARDEN GROVE BLVD
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City | GARDEN GROVE
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State | CA
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Zip | 92843-2255
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Country | US
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Telephone | 714-750-4097
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Fax |
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Provider Business Mailing Address
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Address Line | 616 W MEMORY LN
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City | SANTA ANA
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State | CA
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Zip | 92706-1127
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Country | US
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Telephone | 714-558-7216
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Fax | 714-758-9555
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT24990
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License Number State | CA
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