Healthcare Provider Details

I. General information

NPI: 1396792362
Provider Name (Legal Business Name): JALLER RAAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 CRANDON BLVD
KEY BISCAYNE FL
33149-2753
US

IV. Provider business mailing address

943 CRANDON BLVD
KEY BISCAYNE FL
33149-2753
US

V. Phone/Fax

Practice location:
  • Phone: 305-365-6776
  • Fax: 305-392-1750
Mailing address:
  • Phone: 305-365-6776
  • Fax: 305-392-1750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number686609
License Number StateFL

VIII. Authorized Official

Name: ALFREDO VILLAVERDE ZAYAS
Title or Position: ADMINISTRATOR OWNER
Credential:
Phone: 305-260-9177