Healthcare Provider Details

I. General information

NPI: 1669200382
Provider Name (Legal Business Name): MADELAINE MARTINEZ MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 NW 107TH AVE STE 110
MIAMI FL
33172-3100
US

IV. Provider business mailing address

9890 NW 4TH ST
PEMBROKE PINES FL
33024-6103
US

V. Phone/Fax

Practice location:
  • Phone: 305-964-5426
  • Fax: 305-964-5627
Mailing address:
  • Phone: 754-257-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: