Provider Demographics
NPI:1477059038
Name:AREVALO, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6296 RIVER CREST DR STE K
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0738
Mailing Address - Country:US
Mailing Address - Phone:951-867-3800
Mailing Address - Fax:
Practice Address - Street 1:6296 RIVER CREST DRIVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-867-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XMedicaid