Provider Demographics
NPI:1568850477
Name:TEJEDA, MARCO (PTA)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:TEJEDA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9025 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-2157
Mailing Address - Country:US
Mailing Address - Phone:951-688-3636
Mailing Address - Fax:
Practice Address - Street 1:2989 CROOKED CREEK DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3408
Practice Address - Country:US
Practice Address - Phone:951-675-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5705225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant