Healthcare Provider Details

I. General information

NPI: 1861437931
Provider Name (Legal Business Name): SOTHSIDE MEDICAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8199 NW 74TH AVE 8199
MEDLEY FL
33166-7401
US

IV. Provider business mailing address

8199 NW 74TH AVE 8199
MEDLEY FL
33166-7401
US

V. Phone/Fax

Practice location:
  • Phone: 305-863-3077
  • Fax: 305-863-3079
Mailing address:
  • Phone: 305-863-3077
  • Fax: 305-863-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1013260001
License Number StateFL

VIII. Authorized Official

Name: IGNACIO FIGUEROA
Title or Position: OWNER
Credential:
Phone: 305-863-3077