Healthcare Provider Details

I. General information

NPI: 1255800496
Provider Name (Legal Business Name): LUIS ERNESTO CEBALLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9260 HAMMOCKS BLVD STE 202
MIAMI FL
33196-1584
US

IV. Provider business mailing address

15043 SW 109TH LN
MIAMI FL
33196-2531
US

V. Phone/Fax

Practice location:
  • Phone: 786-353-2900
  • Fax:
Mailing address:
  • Phone: 786-495-2565
  • Fax: 786-364-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-69497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: