Provider Demographics
NPI:1215474390
Name:RECIO, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:RECIO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARK JOSE
Other - Middle Name:
Other - Last Name:RECIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:23910 SUNSET CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1450
Mailing Address - Country:US
Mailing Address - Phone:661-709-0607
Mailing Address - Fax:
Practice Address - Street 1:3110 E GUASTI RD STE 315
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1258
Practice Address - Country:US
Practice Address - Phone:346-376-1702
Practice Address - Fax:909-466-4800
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily