Provider Demographics
NPI:1801382247
Name:TORRES-MALLANTA, MINERVA C
Entity Type:Individual
Prefix:
First Name:MINERVA
Middle Name:C
Last Name:TORRES-MALLANTA
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 1:4732 EDGEBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6221
Mailing Address - Country:US
Mailing Address - Phone:209-406-9800
Mailing Address - Fax:
Practice Address - Street 1:5250 CLAREMONT AVE STE 212
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5700
Practice Address - Country:US
Practice Address - Phone:209-644-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA1387891OtherDRIVER LICENSE
CA582432009OtherPASSPORT