Healthcare Provider Details

I. General information

NPI: 1922752302
Provider Name (Legal Business Name): VICTOR J MARRERO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 L ST
CHULA VISTA CA
91911-1066
US

IV. Provider business mailing address

630 L ST
CHULA VISTA CA
91911-1066
US

V. Phone/Fax

Practice location:
  • Phone: 619-271-7100
  • Fax:
Mailing address:
  • Phone: 619-781-8053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: