Provider Demographics
NPI:1063171411
Name:HERNANDEZ, MARCOS
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MEADOW DR APT 18
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-3955
Mailing Address - Country:US
Mailing Address - Phone:760-235-9285
Mailing Address - Fax:
Practice Address - Street 1:2201 MEADOW DR APT 108
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-3957
Practice Address - Country:US
Practice Address - Phone:760-235-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician