Provider Demographics
NPI:1376665570
Name:MARINO, VINCENT (PT)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:MARINO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 HIDDEN HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-6927
Mailing Address - Country:US
Mailing Address - Phone:954-382-9179
Mailing Address - Fax:877-254-0978
Practice Address - Street 1:3141 HIDDEN HOLLOW LN
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-6927
Practice Address - Country:US
Practice Address - Phone:954-382-9179
Practice Address - Fax:877-254-0978
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0003734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT0003734OtherLICENSE