Provider Demographics
NPI:1659940286
Name:BOLLAIN Y GOYTIA, MARITZA
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:BOLLAIN Y GOYTIA
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 1:508 N SPAULDING AVE # 508 1/2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1842
Mailing Address - Country:US
Mailing Address - Phone:708-860-0401
Mailing Address - Fax:
Practice Address - Street 1:8440 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4254
Practice Address - Country:US
Practice Address - Phone:424-322-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19160171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist