1780217331 NPI number — MACY-ALEXANDRA MAKANA MITRAVICH

Table of content: MACY-ALEXANDRA MAKANA MITRAVICH (NPI 1780217331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780217331 NPI number — MACY-ALEXANDRA MAKANA MITRAVICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITRAVICH
Provider First Name:
MACY-ALEXANDRA
Provider Middle Name:
MAKANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1780217331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 SEA GLASS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92054-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-271-1361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
474 W VERMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92025-6584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-482-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2020

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: ASW93920 , 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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