Provider Demographics
NPI:1386395481
Name:MAGALLANES, MAIRA CONSUELO
Entity type:Individual
Prefix:
First Name:MAIRA
Middle Name:CONSUELO
Last Name:MAGALLANES
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 1:428 S PERRY ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-2528
Mailing Address - Country:US
Mailing Address - Phone:720-366-5579
Mailing Address - Fax:
Practice Address - Street 1:10699 MELODY DR STE 2
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4131
Practice Address - Country:US
Practice Address - Phone:720-507-3841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12-115-0281OtherDRIVERS LICEENSE