Healthcare Provider Details

I. General information

NPI: 1164318002
Provider Name (Legal Business Name): ANDRES ELOY MORA CENTENO SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 NW 7TH ST UNIT 3
FLORIDA CITY FL
33034-2090
US

IV. Provider business mailing address

540 NW 7TH ST UNIT 3
FLORIDA CITY FL
33034-2090
US

V. Phone/Fax

Practice location:
  • Phone: 786-468-6729
  • Fax:
Mailing address:
  • Phone: 786-468-6729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11040230
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: