Provider Demographics
NPI:1558693945
Name:MAURICIO, JUAN MARCIANO (PT)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:MARCIANO
Last Name:MAURICIO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19648 BOTANY BAY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6032
Mailing Address - Country:US
Mailing Address - Phone:951-264-4397
Mailing Address - Fax:
Practice Address - Street 1:19648 BOTANY BAY RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-6032
Practice Address - Country:US
Practice Address - Phone:951-264-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist