Provider Demographics
NPI:1083367924
Name:MAITANO, A LIMITED LIABILITY CORPORATION
Entity Type:Organization
Organization Name:MAITANO, A LIMITED LIABILITY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:CORDIALIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MSORA-KASAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, RDN, DIPACLM
Authorized Official - Phone:951-801-4000
Mailing Address - Street 1:30086 DEW HURST ST
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7646
Mailing Address - Country:US
Mailing Address - Phone:951-801-4000
Mailing Address - Fax:
Practice Address - Street 1:12125 DAY ST STE H308
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-6705
Practice Address - Country:US
Practice Address - Phone:951-801-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAITANO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty