Provider Demographics
NPI:1609389741
Name:YACINO, PETER LOUIS
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:LOUIS
Last Name:YACINO
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 1:4394 BADALI RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-9233
Mailing Address - Country:US
Mailing Address - Phone:941-320-2647
Mailing Address - Fax:
Practice Address - Street 1:4394 BADALI RD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34286-9233
Practice Address - Country:US
Practice Address - Phone:941-320-2647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA75867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist