Provider Demographics
NPI:1477963775
Name:MAYORGA, TAMI MARIE
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:MARIE
Last Name:MAYORGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:MARIE
Other - Last Name:HOMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HAIR REPLACEMENT
Mailing Address - Street 1:350 E CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-5355
Mailing Address - Country:US
Mailing Address - Phone:805-720-4836
Mailing Address - Fax:
Practice Address - Street 1:350 E CLARK AVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5355
Practice Address - Country:US
Practice Address - Phone:805-720-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK433145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist