Healthcare Provider Details

I. General information

NPI: 1306568662
Provider Name (Legal Business Name): MARK CUENCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7035 TURIN PL
EASTVALE CA
92880-6425
US

IV. Provider business mailing address

690 OXFORD ST STE H
CHULA VISTA CA
91911-7117
US

V. Phone/Fax

Practice location:
  • Phone: 619-988-3657
  • Fax:
Mailing address:
  • Phone: 619-409-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95021712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: