Provider Demographics
NPI:1306535182
Name:SWANSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SWANSON
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 1:25937 LAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3838
Mailing Address - Country:US
Mailing Address - Phone:909-419-6741
Mailing Address - Fax:
Practice Address - Street 1:25937 LAWTON AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3838
Practice Address - Country:US
Practice Address - Phone:909-419-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility