Provider Demographics
NPI:1740951045
Name:ARCHIBEQUE, MIA ANJILEE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:ANJILEE
Last Name:ARCHIBEQUE
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 1:3442 HOLLYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-7454
Mailing Address - Country:US
Mailing Address - Phone:760-458-7419
Mailing Address - Fax:
Practice Address - Street 1:3442 HOLLYBERRY DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-7454
Practice Address - Country:US
Practice Address - Phone:760-458-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78733225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist