Healthcare Provider Details

I. General information

NPI: 1588125207
Provider Name (Legal Business Name): JERMAINE JEMELLE MOREIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 W ATLANTIC AVE STE 112
DELRAY BEACH FL
33484-8103
US

IV. Provider business mailing address

15856 TANGERINE BLVD
LOXAHATCHEE FL
33470-3456
US

V. Phone/Fax

Practice location:
  • Phone: 561-674-9996
  • Fax:
Mailing address:
  • Phone: 561-601-3712
  • 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: