Provider Demographics
NPI:1396960134
Name:MARROQUIN, RAFAEL (989057)
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:MARROQUIN
Suffix:
Gender:M
Credentials:989057
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3520
Mailing Address - Country:US
Mailing Address - Phone:951-367-2111
Mailing Address - Fax:951-367-1585
Practice Address - Street 1:4500 BROCKTON AVE
Practice Address - Street 2:SUITE 317
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4090
Practice Address - Country:US
Practice Address - Phone:951-367-2111
Practice Address - Fax:951-367-1585
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA989057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist