Provider Demographics
NPI:1558787127
Name:PINO, AUDREY M
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:M
Last Name:PINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 5TH ST
Mailing Address - Street 2:UNIT E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2454
Mailing Address - Country:US
Mailing Address - Phone:310-246-1904
Mailing Address - Fax:
Practice Address - Street 1:11022 SANTA MONICA BLVD
Practice Address - Street 2:SUITE #440 -SEATON
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7513
Practice Address - Country:US
Practice Address - Phone:310-246-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6006225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist