Provider Demographics
NPI:1477229482
Name:RETUYA, AMADO MARAYAG JR
Entity Type:Individual
Prefix:
First Name:AMADO
Middle Name:MARAYAG
Last Name:RETUYA
Suffix:JR
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 1:4605 THORNBUSH DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-8093
Mailing Address - Country:US
Mailing Address - Phone:951-391-3869
Mailing Address - Fax:
Practice Address - Street 1:4605 THORNBUSH DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-8093
Practice Address - Country:US
Practice Address - Phone:951-391-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA87-1565563Medicaid