Healthcare Provider Details

I. General information

NPI: 1821743121
Provider Name (Legal Business Name): ROBERTO ESCOBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SW 104TH AVE
MIAMI FL
33165-5635
US

IV. Provider business mailing address

4500 SW 104TH AVE
MIAMI FL
33165-5635
US

V. Phone/Fax

Practice location:
  • Phone: 305-833-2975
  • Fax:
Mailing address:
  • Phone: 305-833-2975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-195374
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: