Healthcare Provider Details

I. General information

NPI: 1174962385
Provider Name (Legal Business Name): WILSON FLEMENS JR. RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8939 SW 19TH ST
MIRAMAR FL
33025-7614
US

IV. Provider business mailing address

8939 SW 19TH ST
MIRAMAR FL
33025-7614
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-7115
  • Fax:
Mailing address:
  • Phone: 786-624-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number136130
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: