Provider Demographics
NPI:1942882642
Name:MAYTA, RACHA
Entity Type:Individual
Prefix:
First Name:RACHA
Middle Name:
Last Name:MAYTA
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 1:11225 N 28TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5606
Mailing Address - Country:US
Mailing Address - Phone:623-418-1234
Mailing Address - Fax:
Practice Address - Street 1:11225 N 28TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5606
Practice Address - Country:US
Practice Address - Phone:623-418-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ088914OtherACCESS PROVIDER