Healthcare Provider Details

I. General information

NPI: 1033883574
Provider Name (Legal Business Name): ENT GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SW 69TH AVE STE 140
MIAMI FL
33155-2947
US

IV. Provider business mailing address

2400 SW 69TH AVE STE 140
MIAMI FL
33155-2947
US

V. Phone/Fax

Practice location:
  • Phone: 305-450-1757
  • Fax: 305-265-4844
Mailing address:
  • Phone: 305-450-1757
  • Fax: 305-265-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: OCTAVIO CARRENO
Title or Position: MANAGER
Credential:
Phone: 305-450-1757