Healthcare Provider Details

I. General information

NPI: 1316556376
Provider Name (Legal Business Name): BRYAN A MEJIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 SW 165TH AVE STE 104
MIAMI FL
33193-5827
US

IV. Provider business mailing address

1213 SE 25TH TER
HOMESTEAD FL
33035-2165
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone: 305-340-7728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number20-127151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: