Provider Demographics
NPI:1770859332
Name:MARIANO, HERMAN ALARIC (DPT)
Entity Type:Individual
Prefix:
First Name:HERMAN
Middle Name:ALARIC
Last Name:MARIANO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:HERMAN
Other - Middle Name:ALARIC
Other - Last Name:CARRASCO MARIANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10706 ENSWORTH WAY
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91978-1817
Mailing Address - Country:US
Mailing Address - Phone:734-365-2358
Mailing Address - Fax:
Practice Address - Street 1:2060 OTAY LAKES RD STE 110
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1364
Practice Address - Country:US
Practice Address - Phone:619-373-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015191225100000X
225100000X
CA296028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP33780003OtherMEDICARE PTAN
CA1952394603OtherGROUP NPI
MI1538198700OtherGROUP NPI