Healthcare Provider Details

I. General information

NPI: 1386498590
Provider Name (Legal Business Name): LAZARO DARIEL LLANES LUGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 S UNIVERSITY DR STE 130
DAVIE FL
33328-3832
US

IV. Provider business mailing address

28502 SW 134TH AVE
HOMESTEAD FL
33033-7538
US

V. Phone/Fax

Practice location:
  • Phone: 954-592-8659
  • Fax: 561-516-8183
Mailing address:
  • Phone: 786-617-6457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-329570
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: