Provider Demographics
NPI:1114592961
Name:VINICKY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VINICKY
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 1:5182 EUCALYPTUS DR UNIT 6
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-7180
Mailing Address - Country:US
Mailing Address - Phone:708-674-8376
Mailing Address - Fax:
Practice Address - Street 1:10101 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6103
Practice Address - Country:US
Practice Address - Phone:561-798-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program