Healthcare Provider Details

I. General information

NPI: 1013865492
Provider Name (Legal Business Name): IDALIS FUNDORA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 W 2ND AVE
HIALEAH FL
33010-1529
US

IV. Provider business mailing address

2685 W 2ND AVE
HIALEAH FL
33010-1529
US

V. Phone/Fax

Practice location:
  • Phone: 786-252-1820
  • Fax:
Mailing address:
  • Phone:
  • 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: