Basic Information
| Provider Information | |||||||||
| NPI: | 1003155615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYALA | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUIZ | ||||||||
| OtherFirstName: | MARTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2677 ZOE AVE. SUITE #304 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2677 ZOE AVE. SUITE #304 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2013 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.