Provider Demographics
NPI:1518531243
Name:AQUINO, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:AQUINO
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 1:1160 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5000
Mailing Address - Country:US
Mailing Address - Phone:626-802-7743
Mailing Address - Fax:
Practice Address - Street 1:1160 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5000
Practice Address - Country:US
Practice Address - Phone:626-335-5980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN717738164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty