Provider Demographics
NPI:1265988422
Name:PALACIOS, MARIELA
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:PALACIOS
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 1:150 S ALMA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-2411
Mailing Address - Country:US
Mailing Address - Phone:323-787-9403
Mailing Address - Fax:
Practice Address - Street 1:2999 E STEARNS ST
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-4745
Practice Address - Country:US
Practice Address - Phone:714-255-1346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography