Provider Demographics
NPI:1053761791
Name:MURRIETA, ISSAC
Entity type:Individual
Prefix:MR
First Name:ISSAC
Middle Name:
Last Name:MURRIETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-1130
Mailing Address - Country:US
Mailing Address - Phone:661-342-2211
Mailing Address - Fax:
Practice Address - Street 1:1725 OCEAN FRONT WALK
Practice Address - Street 2:UNIT 600
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-3100
Practice Address - Country:US
Practice Address - Phone:661-342-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6074668343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)