Healthcare Provider Details

I. General information

NPI: 1477024339
Provider Name (Legal Business Name): JOSE O AYALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6066 CREST AVE APT 5
RIVERSIDE CA
92503-1700
US

IV. Provider business mailing address

6066 CREST AVE APT 5
RIVERSIDE CA
92503-1700
US

V. Phone/Fax

Practice location:
  • Phone: 951-250-6801
  • Fax:
Mailing address:
  • Phone: 951-250-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: