Healthcare Provider Details

I. General information

NPI: 1730090838
Provider Name (Legal Business Name): ANTONIO ASCENCIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9477 POINTE RETREAT DR UNIT 23
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

9477 S POINTE RETREAT DR
BLOOMINGTON IN
47401-8449
US

V. Phone/Fax

Practice location:
  • Phone: 317-426-7154
  • Fax:
Mailing address:
  • Phone: 317-426-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: