Healthcare Provider Details

I. General information

NPI: 1760894505
Provider Name (Legal Business Name): MERCEDES SANCRISTOBAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14736 N KENDALL DR
MIAMI FL
33196-1481
US

IV. Provider business mailing address

14937 SW 159TH CT
MIAMI FL
33196-5762
US

V. Phone/Fax

Practice location:
  • Phone: 305-387-3300
  • Fax:
Mailing address:
  • Phone: 786-709-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number641125911048
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: