1760717532 NPI number — MS. VICKI A MAIERLE PERMANENT MAKE UP AR

Table of content: MS. VICKI A MAIERLE PERMANENT MAKE UP AR (NPI 1760717532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760717532 NPI number — MS. VICKI A MAIERLE PERMANENT MAKE UP AR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAIERLE
Provider First Name:
VICKI
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PERMANENT MAKE UP AR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760717532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3970 NOBEL DR
Provider Second Line Business Mailing Address:
#102
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92122-5789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-368-6269
Provider Business Mailing Address Fax Number:
858-457-0669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9834 GENESEE AVE
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-368-6269
Provider Business Practice Location Address Fax Number:
858-457-0669
Provider Enumeration Date:
10/12/2009

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: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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