Provider Demographics
NPI:1942765896
Name:VILLARREAL, MARCOS ANDRES
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:ANDRES
Last Name:VILLARREAL
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 1:6717 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3205
Mailing Address - Country:US
Mailing Address - Phone:602-908-4048
Mailing Address - Fax:
Practice Address - Street 1:6717 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3205
Practice Address - Country:US
Practice Address - Phone:602-908-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor