Healthcare Provider Details

I. General information

NPI: 1134459779
Provider Name (Legal Business Name): BENITO HERRERA MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6741 CORAL WAY #41-42
MIAMI FL
33155-1762
US

IV. Provider business mailing address

6741 CORAL WAY #41-42
MIAMI FL
33155-1762
US

V. Phone/Fax

Practice location:
  • Phone: 786-768-7708
  • Fax:
Mailing address:
  • Phone: 786-768-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberMA 46836
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: