Healthcare Provider Details

I. General information

NPI: 1942505243
Provider Name (Legal Business Name): MIBASO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 KANE CONCOURSE 214
BAY HARBOR ISLANDS FL
33154-2119
US

IV. Provider business mailing address

1045 KANE CONCOURSE 214
BAY HARBOR ISLANDS FL
33154-2119
US

V. Phone/Fax

Practice location:
  • Phone: 786-537-0771
  • Fax:
Mailing address:
  • Phone: 786-537-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberAP2313
License Number StateFL

VIII. Authorized Official

Name: DR. AHUVA GAMLIEL
Title or Position: CEO
Credential: AP
Phone: 786-537-0771