Provider Demographics
NPI:1891483855
Name:BEDFORD, MARCUS ANTONIO JR
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:ANTONIO
Last Name:BEDFORD
Suffix:JR
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:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-0010
Mailing Address - Country:US
Mailing Address - Phone:562-416-3254
Mailing Address - Fax:562-860-4865
Practice Address - Street 1:221 E BARCLAY ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805
Practice Address - Country:US
Practice Address - Phone:562-416-3254
Practice Address - Fax:562-860-4865
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHRPSS003512101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty