Provider Demographics
NPI:1295266609
Name:AMEZCUA, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:AMEZCUA
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 1:108 W VICTORIA STREET
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 W VICTORIA STREET
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90047
Practice Address - Country:US
Practice Address - Phone:310-715-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner