Healthcare Provider Details

I. General information

NPI: 1699290866
Provider Name (Legal Business Name): ROMAN ANGEL MARQUEZ RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 PAJARO ST STE 4
SALINAS CA
93901-3459
US

IV. Provider business mailing address

9015 MURRAY AVE STE 100
GILROY CA
95020-3617
US

V. Phone/Fax

Practice location:
  • Phone: 831-424-6665
  • Fax: 831-424-9717
Mailing address:
  • Phone: 408-665-4908
  • Fax: 408-842-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1446451021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: