Provider Demographics
NPI:1265519409
Name:INDIVIGLIO, MARIO MICHAEL (AP)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:MICHAEL
Last Name:INDIVIGLIO
Suffix:
Gender:M
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 NOTTINGHAM BLVD
Mailing Address - Street 2:#2
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-2770
Mailing Address - Country:US
Mailing Address - Phone:561-703-5930
Mailing Address - Fax:561-655-9542
Practice Address - Street 1:245 NOTTINGHAM BLVD
Practice Address - Street 2:#2
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-2770
Practice Address - Country:US
Practice Address - Phone:561-703-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL882171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist