Provider Demographics
NPI:1508454067
Name:PALOMINO, MARIO E (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:PALOMINO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39895 SQUIRE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3716
Mailing Address - Country:US
Mailing Address - Phone:231-388-3959
Mailing Address - Fax:
Practice Address - Street 1:42500 W 11 MILE RD STE A
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1794
Practice Address - Country:US
Practice Address - Phone:231-388-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty