Provider Demographics
NPI:1245754431
Name:MINTZ, MARLA ELLEN (RE ELECTROLOGIST)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:ELLEN
Last Name:MINTZ
Suffix:
Gender:F
Credentials:RE ELECTROLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11844 W PICO BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1353
Mailing Address - Country:US
Mailing Address - Phone:310-625-8261
Mailing Address - Fax:
Practice Address - Street 1:11844 W PICO BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1353
Practice Address - Country:US
Practice Address - Phone:310-625-8261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9514174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist