=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972846756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELA CELESTE VENTOCILLA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2013
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1145 STURGIS ROAD
-----------------------------------------------------
City | TWENTYNINE PALMS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 UPSHUR AVE APT C
-----------------------------------------------------
City | TWENTYNINE PALMS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92277-9482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-458-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 010127041
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------