Healthcare Provider Details

I. General information

NPI: 1417827718
Provider Name (Legal Business Name): MANUEL QUEVEDO MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MARTIN ST
LAKE PLACID FL
33852-7607
US

IV. Provider business mailing address

120 MARTIN ST
LAKE PLACID FL
33852-7607
US

V. Phone/Fax

Practice location:
  • Phone: 816-273-8118
  • Fax:
Mailing address:
  • Phone: 816-273-8118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-487139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: