Healthcare Provider Details

I. General information

NPI: 1679384382
Provider Name (Legal Business Name): JORGE E FUNDICHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12164 NW 23RD PATH
MIAMI FL
33167-1490
US

IV. Provider business mailing address

12164 NW 23RD PATH
MIAMI FL
33167-1490
US

V. Phone/Fax

Practice location:
  • Phone: 786-853-0969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-405040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: