MEDICARE: MR. VINCENT ANGELO GLAVIANO NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN2295490	MA
2	363LF0000X	Family Nurse Practitioner	95017783	CA

General Provider Information

NPI Number	:	1205207594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VINCENT ANGELO GLAVIANO NP

Provider Business Mailing Address
First Line	:	4140 W 190TH ST
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90504-5513
Country	:	US
Telephone Number	:	424-315-2395
Fax Number	:	424-315-2396

Provider Business Practice Location Address
First Line	:	12746 W JEFFERSON BLVD STE 3000
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90094-2885
Country	:	US
Telephone Number	:	424-315-2395
Fax Number	:	424-315-2396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	01/20/2022

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