Healthcare Provider Details

I. General information

NPI: 1730968355
Provider Name (Legal Business Name): JUAN MANUEL PORTALES RAMOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W 12TH ST APT 22
HIALEAH FL
33010-3460
US

IV. Provider business mailing address

190 W 12TH ST APT 22
HIALEAH FL
33010-3460
US

V. Phone/Fax

Practice location:
  • Phone: 786-371-3938
  • Fax:
Mailing address:
  • Phone: 786-371-3938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-288544
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: