Healthcare Provider Details

I. General information

NPI: 1710684832
Provider Name (Legal Business Name): GINO LAMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 W 23RD AVE STE 2
HIALEAH FL
33016-5560
US

IV. Provider business mailing address

8020 W 23RD AVE STE 2
HIALEAH FL
33016-5560
US

V. Phone/Fax

Practice location:
  • Phone: 954-849-4292
  • Fax:
Mailing address:
  • Phone: 954-849-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number22091334MU
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: