Provider Demographics
NPI:1902265572
Name:MASON, VIVARIA
Entity Type:Individual
Prefix:MRS
First Name:VIVARIA
Middle Name:
Last Name:MASON
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 1:1304 FOREST DALE DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-2340
Mailing Address - Country:US
Mailing Address - Phone:678-447-4574
Mailing Address - Fax:251-341-5613
Practice Address - Street 1:1304 FOREST DALE DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-2340
Practice Address - Country:US
Practice Address - Phone:678-447-4574
Practice Address - Fax:251-341-5613
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL621399374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide