Healthcare Provider Details

I. General information

NPI: 1255149118
Provider Name (Legal Business Name): LOURDES M MENDEZ MIURA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N CENTRAL AVE STE 110
KISSIMMEE FL
34741-4439
US

IV. Provider business mailing address

4096 LAKE BOSSE VIEW DR
ORLANDO FL
32810-1905
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax: 877-399-5578
Mailing address:
  • Phone: 407-970-4294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: