Healthcare Provider Details

I. General information

NPI: 1396258570
Provider Name (Legal Business Name): MENDEL SURPRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
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

4507 CYCAD LN
BOYNTON BEACH FL
33436-7320
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone: 561-843-6925
  • Fax: 561-752-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: