MEDICARE: MAYRA JUDY BRISENO

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	225400000X	Rehabilitation Practitioner
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1598263592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA JUDY BRISENO

Provider Business Mailing Address
First Line	:	1216 W AVENUE J STE 300
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2944
Country	:	US
Telephone Number	:	661-341-3495
Fax Number	:

Provider Business Practice Location Address
First Line	:	1216 W AVENUE J STE 300
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2944
Country	:	US
Telephone Number	:	661-341-3495
Fax Number	:

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

Provider Enumeration Date	:	01/25/2018
Last Update Date	:	08/09/2023

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