Healthcare Provider Details

I. General information

NPI: 1124161708
Provider Name (Legal Business Name): MARCO ANTONIO CAZARES D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81-480 AVENUE 46. SUITE 102
INDIO CA
92220
US

IV. Provider business mailing address

81-480 AVENUE 46. SUITE 102
INDIO CA
92220
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-5955
  • Fax: 760-863-5655
Mailing address:
  • Phone: 760-863-5955
  • Fax: 760-863-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number23477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: