Healthcare Provider Details

I. General information

NPI: 1285512848
Provider Name (Legal Business Name): MARC-RYAN ESCALONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 HALE PL
CHULA VISTA CA
91914-3504
US

IV. Provider business mailing address

1176 SPARROW LAKE RD
CHULA VISTA CA
91913-2890
US

V. Phone/Fax

Practice location:
  • Phone: 619-948-8075
  • Fax:
Mailing address:
  • Phone: 619-948-8075
  • Fax: 619-948-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: