MEDICARE: LOURDES MEDINA

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-18-70355

General Provider Information

NPI Number	:	1679114599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOURDES MEDINA

Provider Business Mailing Address
First Line	:	565 ALBATROSS ST
Second Line	:
City	:	MIAMI SPRINGS
State	:	FL
Zip	:	33166-3904
Country	:	US
Telephone Number	:	786-346-8904
Fax Number	:

Provider Business Practice Location Address
First Line	:	565 ALBATROSS ST
Second Line	:
City	:	MIAMI SPRINGS
State	:	FL
Zip	:	33166-3904
Country	:	US
Telephone Number	:	786-346-8904
Fax Number	:

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

Provider Enumeration Date	:	10/02/2019
Last Update Date	:	10/02/2019

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Directions to “ LOURDES MEDINA ” Practice Location

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