MEDICARE: MAYURI C FUENTES RODRIGUEZ

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	106S00000X	Behavior Technician	RBT-23-271977	FL

General Provider Information

NPI Number	:	1215703095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYURI C FUENTES RODRIGUEZ

Provider Business Mailing Address
First Line	:	5441 NW 184TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-5344
Country	:	US
Telephone Number	:	786-482-1405
Fax Number	:

Provider Business Practice Location Address
First Line	:	5441 NW 184TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-5344
Country	:	US
Telephone Number	:	786-482-1405
Fax Number	:

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

Provider Enumeration Date	:	12/01/2023
Last Update Date	:	12/01/2023

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