Healthcare Provider Details

I. General information

NPI: 1467362442
Provider Name (Legal Business Name): MARCUS ANTHONY MINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 MALLORY ST APT B
SAN BERNARDINO CA
92407-6484
US

IV. Provider business mailing address

2226 MALLORY ST APT B
SAN BERNARDINO CA
92407-6484
US

V. Phone/Fax

Practice location:
  • Phone: 909-376-3069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: