Healthcare Provider Details

I. General information

NPI: 1124230081
Provider Name (Legal Business Name): MARIO TUDELA MA-1936687
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 33RD AVE
MIAMI FL
33125-4106
US

IV. Provider business mailing address

6348 W 22ND LN
HIALEAH FL
33016-3925
US

V. Phone/Fax

Practice location:
  • Phone: 305-646-0062
  • Fax:
Mailing address:
  • Phone: 305-557-8780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA1936687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: