Provider Demographics
NPI:1528437951
Name:FARIAS, MARCOS
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:FARIAS
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 1:3108 HOLLYDALE DRIVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039
Mailing Address - Country:US
Mailing Address - Phone:323-717-0720
Mailing Address - Fax:
Practice Address - Street 1:3108 HOLLYDALE DRIVE APT 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039
Practice Address - Country:US
Practice Address - Phone:323-717-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN230135164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse