Provider Demographics
NPI:1194504498
Name:CHACON VILLANUEVA, MARCOS ELISEO
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:ELISEO
Last Name:CHACON VILLANUEVA
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 1:200 E ROWLAND ST # 237
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3146
Mailing Address - Country:US
Mailing Address - Phone:323-712-1840
Mailing Address - Fax:
Practice Address - Street 1:851 S SUNSET AVE APT T220
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5510
Practice Address - Country:US
Practice Address - Phone:323-712-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02271594246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty