Healthcare Provider Details

I. General information

NPI: 1255842829
Provider Name (Legal Business Name): JUAN CARLOS FAGUNDO PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26055 SW 144TH AVE APT 206
HOMESTEAD FL
33032-5653
US

IV. Provider business mailing address

26055 SW 144TH AVE APT 206
HOMESTEAD FL
33032-5653
US

V. Phone/Fax

Practice location:
  • Phone: 305-303-2482
  • Fax:
Mailing address:
  • Phone: 305-303-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: