Provider Demographics
NPI:1588042279
Name:MOLINA, MARIO SR
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MOLINA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:LUIS
Other - Last Name:MOLINA
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:28810 SW 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-2543
Mailing Address - Country:US
Mailing Address - Phone:786-444-6003
Mailing Address - Fax:786-504-2665
Practice Address - Street 1:28810 SW 154TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-2543
Practice Address - Country:US
Practice Address - Phone:786-444-6003
Practice Address - Fax:786-504-2665
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL473947961Other473947961