Provider Demographics
NPI:1679226633
Name:VARGAS, MIRELLY
Entity Type:Individual
Prefix:
First Name:MIRELLY
Middle Name:
Last Name:VARGAS
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 1:32675 MISSION TRL APT 9
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2326
Mailing Address - Country:US
Mailing Address - Phone:951-413-4204
Mailing Address - Fax:
Practice Address - Street 1:2560 N PERRIS BLVD STE N1
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-3251
Practice Address - Country:US
Practice Address - Phone:951-940-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-KXEVU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist