Provider Demographics
NPI:1841495298
Name:MARQUEZ, JACK ARTURO (ATC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ARTURO
Last Name:MARQUEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 KNOLL RD
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5857
Mailing Address - Country:US
Mailing Address - Phone:760-842-8202
Mailing Address - Fax:
Practice Address - Street 1:17500 PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-9547
Practice Address - Country:US
Practice Address - Phone:951-601-3028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist