Healthcare Provider Details

I. General information

NPI: 1134410079
Provider Name (Legal Business Name): REGLA TRUJILLO CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7282 SW 114TH PL
MIAMI FL
33173-2607
US

IV. Provider business mailing address

11422 SW 73RD TER
MIAMI FL
33173-2692
US

V. Phone/Fax

Practice location:
  • Phone: 786-457-7784
  • Fax: 786-360-4310
Mailing address:
  • Phone: 786-457-7784
  • Fax: 786-360-4310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberCRT 58464
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: