Healthcare Provider Details

I. General information

NPI: 1992273510
Provider Name (Legal Business Name): COFFEESTONE HOLDINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14505 COMMERCE WAY STE 800
MIAMI LAKES FL
33016-1599
US

IV. Provider business mailing address

14505 COMMERCE WAY STE 800
MIAMI LAKES FL
33016-1599
US

V. Phone/Fax

Practice location:
  • Phone: 305-821-8861
  • Fax: 305-821-8783
Mailing address:
  • Phone: 305-821-8861
  • Fax: 305-821-8783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTEL GEORGE SAMUELS
Title or Position: PRESIDENT
Credential: MD
Phone: 361-673-3111