Healthcare Provider Details

I. General information

NPI: 1629931431
Provider Name (Legal Business Name): JACK ANTHONY SAMPEDRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 N KENDALL DR
MIAMI FL
33176-2197
US

IV. Provider business mailing address

7400 SW 64TH ST
SOUTH MIAMI FL
33143-2802
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-1960
  • Fax:
Mailing address:
  • Phone: 305-323-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number585960
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: