Healthcare Provider Details

I. General information

NPI: 1962088120
Provider Name (Legal Business Name): EDGARDO ARIEL DE LEON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
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

501 E DANIA BEACH BLVD APT 1L
DANIA BEACH FL
33004-3010
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone: 954-651-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: