Provider Demographics
NPI:1780959676
Name:MARIANO PRIME LLC
Entity type:Organization
Organization Name:MARIANO PRIME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SURLA
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-649-5833
Mailing Address - Street 1:255 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3209
Mailing Address - Country:US
Mailing Address - Phone:671-649-5833
Mailing Address - Fax:671-649-5830
Practice Address - Street 1:255 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3209
Practice Address - Country:US
Practice Address - Phone:671-649-5833
Practice Address - Fax:671-649-5830
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARIANO PRIME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies