Provider Demographics
NPI:1922695816
Name:AYALA, ROBERTO ELI
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ELI
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 1:11674 VALVERDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3337
Mailing Address - Country:US
Mailing Address - Phone:951-565-0259
Mailing Address - Fax:
Practice Address - Street 1:901 VIA PIEMONTE STE 120
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-8501
Practice Address - Country:US
Practice Address - Phone:888-871-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18954225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist