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General NPI Number Information
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NPI Number | 1700598018
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Entity Type | Individual
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Provider Name | MARINA ROSE MALDONADO
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Gender | Female
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Dates
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Enumeration Date | 12/19/2022
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Last Update Date | 12/19/2022
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Provider Practice Location Address
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Address Line | 3150 PLATEAU DR LOT 303
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City | COLUMBUS
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State | GA
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Zip | 31903-5400
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Country | US
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Telephone | 706-322-3773
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Fax |
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Provider Business Mailing Address
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Address Line | 4402 RIVERCHASE DR APT 4106
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City | PHENIX CITY
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State | AL
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Zip | 36867-7551
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Country | US
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Telephone | 706-223-8847
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Fax |
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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 | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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