Healthcare Provider Details

I. General information

NPI: 1598422974
Provider Name (Legal Business Name): HANS CRIS ANGELO MARAVILLA CUDAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29228 US HIGHWAY 19 N
CLEARWATER FL
33761-2101
US

IV. Provider business mailing address

300 INTERNATIONAL PARKWAY SUITE 200
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 727-351-4191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: