Healthcare Provider Details

I. General information

NPI: 1316582984
Provider Name (Legal Business Name): MICHAEL TIMOTHY CERVANTES MANEJE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

1863 SW 173RD AVE
MIRAMAR FL
33029-5518
US

V. Phone/Fax

Practice location:
  • Phone: 561-965-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11005963
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9338690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: