Provider Demographics
NPI:1447013305
Name:CHAVEZ, MAYRA R
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:R
Last Name:CHAVEZ
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 1:4244 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4053
Mailing Address - Country:US
Mailing Address - Phone:909-545-2176
Mailing Address - Fax:
Practice Address - Street 1:15911 POMONA RINCON RD
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5566
Practice Address - Country:US
Practice Address - Phone:909-248-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty