Provider Demographics
NPI:1568159911
Name:MARYVALE
Entity Type:Organization
Organization Name:MARYVALE
Other - Org Name:MARYVALE COMMUNITY BASED SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMMUNITY BASED
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-263-9133
Mailing Address - Street 1:7600 E. GRAVES AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3414
Mailing Address - Country:US
Mailing Address - Phone:626-280-6510
Mailing Address - Fax:
Practice Address - Street 1:7600 E. GRAVES AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3414
Practice Address - Country:US
Practice Address - Phone:626-263-9133
Practice Address - Fax:626-359-4285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVALE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-18
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health