Provider Demographics
NPI:1336390111
Name:MIJARES, MARISA SUZANNA (LAC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:SUZANNA
Last Name:MIJARES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 CASS ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4518
Mailing Address - Country:US
Mailing Address - Phone:831-402-6157
Mailing Address - Fax:
Practice Address - Street 1:1011 CASS ST
Practice Address - Street 2:SUITE 112
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4518
Practice Address - Country:US
Practice Address - Phone:831-402-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11416171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist