Healthcare Provider Details

I. General information

NPI: 1164559464
Provider Name (Legal Business Name): MARIAL ESCOTO BONILLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 S WATERMAN AVE
EL CENTRO CA
92243-4142
US

IV. Provider business mailing address

2138 S 14TH ST
EL CENTRO CA
92243-4326
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-1436
  • Fax:
Mailing address:
  • Phone: 760-353-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: