Healthcare Provider Details

I. General information

NPI: 1902554553
Provider Name (Legal Business Name): LINO ROBERTO ALFONSO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15680 SW 88TH ST STE 201
MIAMI FL
33196-1160
US

IV. Provider business mailing address

15680 SW 88TH ST STE 201
MIAMI FL
33196-1160
US

V. Phone/Fax

Practice location:
  • Phone: 305-517-1219
  • Fax: 305-203-0546
Mailing address:
  • Phone: 305-517-1219
  • Fax: 305-203-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPTA31245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: