Healthcare Provider Details

I. General information

NPI: 1366088122
Provider Name (Legal Business Name): MARCUS DAERIOUS GITCHUWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

9669 PALMETTO AVE
FONTANA CA
92335-5907
US

V. Phone/Fax

Practice location:
  • Phone: 626-630-7396
  • Fax:
Mailing address:
  • Phone: 626-232-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: