Healthcare Provider Details

I. General information

NPI: 1184286890
Provider Name (Legal Business Name): BARDISA LYL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7374 SW 93RD AVE STE 202
MIAMI FL
33173-3246
US

IV. Provider business mailing address

7374 SW 93RD AVE STE 202
MIAMI FL
33173-3246
US

V. Phone/Fax

Practice location:
  • Phone: 305-661-2002
  • Fax:
Mailing address:
  • Phone: 305-661-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSALIND BARDISA
Title or Position: DOCTOR
Credential:
Phone: 305-661-2002