Provider Demographics
NPI:1215736749
Name:BUENAVENTURA, MARCO ELIJAH
Entity type:Individual
Prefix:
First Name:MARCO ELIJAH
Middle Name:
Last Name:BUENAVENTURA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 TROUVILLE LN UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-4942
Mailing Address - Country:US
Mailing Address - Phone:619-748-4998
Mailing Address - Fax:
Practice Address - Street 1:1430 TROUVILLE LN UNIT 2
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-4942
Practice Address - Country:US
Practice Address - Phone:619-748-4998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-25-415969106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician