Healthcare Provider Details

I. General information

NPI: 1710595590
Provider Name (Legal Business Name): CARLOS A MOYANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 SW 100TH AVE
MIAMI FL
33165-5757
US

IV. Provider business mailing address

4651 SW 100TH AVE
MIAMI FL
33165-5757
US

V. Phone/Fax

Practice location:
  • Phone: 305-548-9180
  • Fax:
Mailing address:
  • Phone: 305-548-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-124288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: