Provider Demographics
NPI:1063250256
Name:MAYORAL, IRIS
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:MAYORAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-2077
Mailing Address - Fax:310-248-8252
Practice Address - Street 1:127 S SAN VICENTE BLVD STE A6100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3311
Practice Address - Country:US
Practice Address - Phone:310-423-2077
Practice Address - Fax:310-248-8252
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031195363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health