MEDICARE: IRIDIAN RAFAELA MARQUINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	BACB702046	GA

General Provider Information

NPI Number	:	1366115925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRIDIAN RAFAELA MARQUINA

Provider Business Mailing Address
First Line	:	3932 MILLWOOD LN NW
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2623
Country	:	US
Telephone Number	:	770-771-2743
Fax Number	:

Provider Business Practice Location Address
First Line	:	3775 VENTURE DR STE M101
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-5217
Country	:	US
Telephone Number	:	470-610-4222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	07/29/2021

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