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General NPI Number Information
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NPI Number | 1245090745
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Entity Type | Individual
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Provider Name | MARCO ANTONIO
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Gender | Male
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Dates
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Enumeration Date | 03/21/2024
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Last Update Date | 03/22/2024
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Provider Practice Location Address
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Address Line | 11611 SAN VICENTE BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90049-5106
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Country | US
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Telephone | 925-476-1767
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Fax |
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Provider Business Mailing Address
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Address Line | 3020 ROWENA AVE APT 102
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City | LOS ANGELES
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State | CA
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Zip | 90039-2081
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Country | US
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Telephone | 818-209-0336
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 91285
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License Number State | CA
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