Healthcare Provider Details

I. General information

NPI: 1205592656
Provider Name (Legal Business Name): SUPRA MEDICAL GROUP II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 72ND ST STE 387
MIAMI FL
33173-3020
US

IV. Provider business mailing address

10300 SW 72ND ST STE 387
MIAMI FL
33173-3020
US

V. Phone/Fax

Practice location:
  • Phone: 305-200-5210
  • Fax: 305-200-5780
Mailing address:
  • Phone: 305-200-5210
  • Fax: 305-200-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KLEYDSON DA SILVA
Title or Position: CEO
Credential:
Phone: 305-200-5210