Provider Demographics
NPI:1104420553
Name:CUSTURA, MARIA
Entity type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:
Last Name:CUSTURA
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 1:6924 LAUREL OAK WAY
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3108
Mailing Address - Country:US
Mailing Address - Phone:916-595-5738
Mailing Address - Fax:
Practice Address - Street 1:6924 LAUREL OAK WAY
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3108
Practice Address - Country:US
Practice Address - Phone:191-659-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA342700811310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility