Basic Information
| Provider Information | |||||||||
| NPI: | 1679824619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CATC II | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 SPRUCE ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925077403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513576926 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 SPRUCE ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925077403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513576926 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2012 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | Y |
No ID Information.