Healthcare Provider Details

I. General information

NPI: 1801042437
Provider Name (Legal Business Name): RAIDEN LOPEZ-CARRILLO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7660 SW 134TH CT
MIAMI FL
33183-3325
US

IV. Provider business mailing address

7660 SW 134TH CT
MIAMI FL
33183-3325
US

V. Phone/Fax

Practice location:
  • Phone: 305-728-9949
  • Fax:
Mailing address:
  • Phone: 305-728-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9418218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: