Healthcare Provider Details

I. General information

NPI: 1629794441
Provider Name (Legal Business Name): CARLOS ENRIQUE BUENO SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 79TH PL APT 101
HIALEAH FL
33014-4342
US

IV. Provider business mailing address

211 W 79TH PL APT 101
HIALEAH FL
33014-4342
US

V. Phone/Fax

Practice location:
  • Phone: 786-724-5430
  • Fax:
Mailing address:
  • Phone: 786-724-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number22-563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: