Healthcare Provider Details

I. General information

NPI: 1841860608
Provider Name (Legal Business Name): LUIS MANUEL MARTIN MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6464 N MIAMI AVE
MIAMI FL
33150-4520
US

IV. Provider business mailing address

6464 N MIAMI AVE
MIAMI FL
33150-4520
US

V. Phone/Fax

Practice location:
  • Phone: 305-756-8890
  • Fax: 305-758-5769
Mailing address:
  • Phone: 305-756-8890
  • Fax: 305-758-5769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06210540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: