Healthcare Provider Details

I. General information

NPI: 1528673613
Provider Name (Legal Business Name): MARK STEVEN VIDAL MARRERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 TAMIAMI TRL N
NAPLES FL
34103-2853
US

IV. Provider business mailing address

5050 TAMIAMI TRL N
NAPLES FL
34103-2853
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-0675
  • Fax:
Mailing address:
  • Phone: 239-351-0675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-135484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: