Provider Demographics
NPI:1366867624
Name:MOUTAFIS, MARINO (REG AC)
Entity Type:Individual
Prefix:
First Name:MARINO
Middle Name:
Last Name:MOUTAFIS
Suffix:
Gender:M
Credentials:REG AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7115 ORCHARD LAKE RD STE 410
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3655
Mailing Address - Country:US
Mailing Address - Phone:248-432-2846
Mailing Address - Fax:248-757-2172
Practice Address - Street 1:7115 ORCHARD LAKE RD STE 410
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3655
Practice Address - Country:US
Practice Address - Phone:248-432-2846
Practice Address - Fax:248-757-2172
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5401000071171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist