Provider Demographics
NPI:1508360769
Name:MININO, VIRGILIO ANTONIO
Entity Type:Individual
Prefix:
First Name:VIRGILIO
Middle Name:ANTONIO
Last Name:MININO
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 1:701 SW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1076
Mailing Address - Country:US
Mailing Address - Phone:954-687-5936
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:701 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33023-1076
Practice Address - Country:US
Practice Address - Phone:954-687-5936
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician