Healthcare Provider Details

I. General information

NPI: 1932922606
Provider Name (Legal Business Name): SAMUEL MARINO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 107
RIVERSIDE CA
92501-4006
US

IV. Provider business mailing address

4500 BROCKTON AVE STE 107
RIVERSIDE CA
92501-4006
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-2760
  • Fax:
Mailing address:
  • Phone: 951-276-2760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95032837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: