Healthcare Provider Details

I. General information

NPI: 1174337653
Provider Name (Legal Business Name): MARCO MARQUEZ CAMPOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W HOFFER ST
BANNING CA
92220-2348
US

IV. Provider business mailing address

6235 RIVER CREST DR STE N
RIVERSIDE CA
92507-0758
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-7561
  • Fax:
Mailing address:
  • Phone: 951-653-7561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: