Healthcare Provider Details

I. General information

NPI: 1407100530
Provider Name (Legal Business Name): LEONIDAS FENELON RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 FAIRWAY BLVD
MIRAMAR FL
33023-6500
US

IV. Provider business mailing address

7531 FAIRWAY BLVD
MIRAMAR FL
33023-6500
US

V. Phone/Fax

Practice location:
  • Phone: 954-383-1851
  • Fax:
Mailing address:
  • Phone: 954-383-1851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRT11776
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2278G1100X
TaxonomyGeneral Care Certified Respiratory Therapist
License NumberRT11776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: