Provider Demographics
NPI:1881231504
Name:BALBUENA, MARVIN (COTA)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:BALBUENA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 E CALLE BAJA DR
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2902
Mailing Address - Country:US
Mailing Address - Phone:626-736-7471
Mailing Address - Fax:
Practice Address - Street 1:3241 E CALLE BAJA DR
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-2902
Practice Address - Country:US
Practice Address - Phone:626-736-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4451224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant