Healthcare Provider Details

I. General information

NPI: 1508361247
Provider Name (Legal Business Name): THOMAS MAMROSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-7590
  • Fax: 305-585-7580
Mailing address:
  • Phone: 305-585-7590
  • Fax: 305-585-7580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN3329952
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: