Provider Demographics
NPI:1649681123
Name:AQUINO, LUZ B
Entity type:Individual
Prefix:
First Name:LUZ
Middle Name:B
Last Name:AQUINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 E WIGWAM AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2247
Mailing Address - Country:US
Mailing Address - Phone:702-250-0388
Mailing Address - Fax:
Practice Address - Street 1:395 E WIGWAM AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2247
Practice Address - Country:US
Practice Address - Phone:702-250-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV104100000XMedicaid