Healthcare Provider Details

I. General information

NPI: 1275354953
Provider Name (Legal Business Name): NEW IMAGE THERAPY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15271 NW 60TH AVE STE 101
MIAMI LAKES FL
33014-2431
US

IV. Provider business mailing address

15271 NW 60TH AVE STE 101
MIAMI LAKES FL
33014-2431
US

V. Phone/Fax

Practice location:
  • Phone: 786-398-1892
  • Fax:
Mailing address:
  • Phone: 786-398-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: AMADOR REYES
Title or Position: CONSULTANY
Credential: AUTHORIZED DELEGATE
Phone: 786-253-7699