Healthcare Provider Details

I. General information

NPI: 1336849710
Provider Name (Legal Business Name): JORGE MANUEL LAZO DE LA VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7971 RIVIERA BLVD STE 203
MIRAMAR FL
33023-6446
US

IV. Provider business mailing address

1483 W 44TH TER
HIALEAH FL
33012-7675
US

V. Phone/Fax

Practice location:
  • Phone: 786-508-3245
  • Fax: 561-634-2814
Mailing address:
  • Phone: 786-609-5043
  • Fax: 561-634-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-259401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: