Healthcare Provider Details

I. General information

NPI: 1861090532
Provider Name (Legal Business Name): SEBASTIAN ALEXEY GELLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16325 SW 288TH ST
HOMESTEAD FL
33033-1020
US

IV. Provider business mailing address

10000 NW 5TH LN
MIAMI FL
33172-4067
US

V. Phone/Fax

Practice location:
  • Phone: 305-245-2720
  • Fax:
Mailing address:
  • Phone: 305-746-5203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: