Healthcare Provider Details

I. General information

NPI: 1316139694
Provider Name (Legal Business Name): MARIO LUQUE CSA-FA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3078 CLAIRMONT RD NE APT 522
ATLANTA GA
30329-1666
US

IV. Provider business mailing address

3078 CLAIRMONT RD NE APT 522
ATLANTA GA
30329-1666
US

V. Phone/Fax

Practice location:
  • Phone: 404-668-6112
  • Fax:
Mailing address:
  • Phone: 404-668-6112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: