Provider Demographics
NPI:1922740497
Name:SANTOS, MIRELLA MARYBELL
Entity Type:Individual
Prefix:
First Name:MIRELLA
Middle Name:MARYBELL
Last Name:SANTOS
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 1:10417 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:CA
Mailing Address - Zip Code:93241-1726
Mailing Address - Country:US
Mailing Address - Phone:661-845-5100
Mailing Address - Fax:
Practice Address - Street 1:10417 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:CA
Practice Address - Zip Code:93241-1726
Practice Address - Country:US
Practice Address - Phone:661-845-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program