Healthcare Provider Details

I. General information

NPI: 1295208908
Provider Name (Legal Business Name): RUDY MARMOLEJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N LAKE AVE # 150
PASADENA CA
91104-2301
US

IV. Provider business mailing address

1450 N LAKE AVE # 150
PASADENA CA
91104-2301
US

V. Phone/Fax

Practice location:
  • Phone: 626-794-1161
  • Fax:
Mailing address:
  • Phone: 626-794-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: