Provider Demographics
NPI:1477033678
Name:ATILANO, MARK ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:ATILANO
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 1:12461 BALSAM RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-9474
Mailing Address - Country:US
Mailing Address - Phone:760-792-2860
Mailing Address - Fax:
Practice Address - Street 1:12461 BALSAM RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-9474
Practice Address - Country:US
Practice Address - Phone:760-792-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle