1275907909 NPI number — MARIA LUISA FAVELA CASTRO

Table of content: MARIA LUISA FAVELA CASTRO (NPI 1275907909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275907909 NPI number — MARIA LUISA FAVELA CASTRO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVELA CASTRO
Provider First Name:
MARIA
Provider Middle Name:
LUISA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275907909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3387
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92342-3387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-617-4442
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15095 AMARGOSA RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-245-4695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  142220 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 125291 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9983 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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