Provider Demographics
NPI:1245090745
Name:ANTONIO, MARCO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:ANTONIO
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 1:3020 ROWENA AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2081
Mailing Address - Country:US
Mailing Address - Phone:818-209-0336
Mailing Address - Fax:
Practice Address - Street 1:11611 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5106
Practice Address - Country:US
Practice Address - Phone:925-476-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91285225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist