Healthcare Provider Details

I. General information

NPI: 1841641982
Provider Name (Legal Business Name): DORA MARILUCY BETANCOURTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8175 NW 12TH ST SUITE 306
DORAL FL
33126-1828
US

IV. Provider business mailing address

8175 NW 12TH ST SUITE 306
DORAL FL
33126-1828
US

V. Phone/Fax

Practice location:
  • Phone: 786-845-0164
  • Fax:
Mailing address:
  • Phone: 786-845-0164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9298990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: