Healthcare Provider Details

I. General information

NPI: 1689312704
Provider Name (Legal Business Name): JUSTIN NATHAN YACAB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 NE 12TH AVE
HOMESTEAD FL
33030-6261
US

IV. Provider business mailing address

183 NE 12TH AVE
HOMESTEAD FL
33030-6261
US

V. Phone/Fax

Practice location:
  • Phone: 786-257-9364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-125075
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: