MEDICARE: IVAN MACIAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95120899	CA

General Provider Information

NPI Number	:	1265930846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN MACIAS

Provider Business Mailing Address
First Line	:	1320 PLAZA UNION CT
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-4105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 UNION PLAZA CT
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-5659
Country	:	US
Telephone Number	:	--
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2018
Last Update Date	:	03/13/2018

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Directions to “ IVAN MACIAS ” Practice Location

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