Healthcare Provider Details

I. General information

NPI: 1598465601
Provider Name (Legal Business Name): MARIO ZAVALA-HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27777 INKSTER RD STE 100
FARMINGTON HILLS MI
48334-5312
US

IV. Provider business mailing address

8300 JEFFERSON ST NE SUITE B 8300 JEFFERSON ST NE SUITE B
ALBUQUERQUE NM
87113-1734
US

V. Phone/Fax

Practice location:
  • Phone: 248-436-4400
  • Fax:
Mailing address:
  • Phone: 248-436-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: