Healthcare Provider Details

I. General information

NPI: 1063918274
Provider Name (Legal Business Name): YANCARLOS ORTEGA GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6914 W 24TH LN
HIALEAH FL
33016-5471
US

IV. Provider business mailing address

6914 W 24TH LN
HIALEAH FL
33016-5471
US

V. Phone/Fax

Practice location:
  • Phone: 786-351-0408
  • Fax:
Mailing address:
  • Phone: 786-351-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: