Provider Demographics
NPI:1053074906
Name:AYALA, MARCO ALEXIS
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ALEXIS
Last Name:AYALA
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 1:2851 BEDFORD LN APT 43
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-3561
Mailing Address - Country:US
Mailing Address - Phone:909-731-2704
Mailing Address - Fax:
Practice Address - Street 1:2851 BEDFORD LN APT 43
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-3561
Practice Address - Country:US
Practice Address - Phone:909-731-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty