Healthcare Provider Details

I. General information

NPI: 1710653894
Provider Name (Legal Business Name): SD GLOW AND HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 NW 36TH ST
MIAMI FL
33142-4914
US

IV. Provider business mailing address

3624 NW 36TH ST
MIAMI FL
33142-4914
US

V. Phone/Fax

Practice location:
  • Phone: 305-773-3971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAI GENDRIZ
Title or Position: OWNER
Credential:
Phone: 305-251-2500