1548779788 NPI number — MARI JOSEPHINE SY CUSTODIO OTR/L

Table of content: IDELYS GARCIA ORTIZ FNP (NPI 1912678137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548779788 NPI number — MARI JOSEPHINE SY CUSTODIO OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUSTODIO
Provider First Name:
MARI JOSEPHINE
Provider Middle Name:
SY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CUSTODIO
Provider Other First Name:
JOSEPHINE
Provider Other Middle Name:
SY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548779788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22704 VOSE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91307-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-486-2884
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14445 OLIVE VIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91342-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-210-4245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4037 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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