Provider Demographics
NPI:1235947458
Name:ALVARADO AYALA, MARIO BENJAMIN
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:BENJAMIN
Last Name:ALVARADO AYALA
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 1:1041 N WANDA DR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-1553
Mailing Address - Country:US
Mailing Address - Phone:714-321-9519
Mailing Address - Fax:
Practice Address - Street 1:3430 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-3104
Practice Address - Country:US
Practice Address - Phone:323-722-8481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist