Healthcare Provider Details

I. General information

NPI: 1629899984
Provider Name (Legal Business Name): RENATO CARLO SOTELO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 NE 28TH AVE STE 305
AVENTURA FL
33180-1421
US

IV. Provider business mailing address

9960 NW 116TH WAY STE 13
MEDLEY FL
33178-1175
US

V. Phone/Fax

Practice location:
  • Phone: 305-933-5993
  • Fax: 305-993-9415
Mailing address:
  • Phone: 786-924-1311
  • Fax: 786-924-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024084788
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11036267
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: