Healthcare Provider Details

I. General information

NPI: 1831361179
Provider Name (Legal Business Name): JERRY WIMBERLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 NE MIAMI CT
NORTH MIAMI FL
33161-5354
US

IV. Provider business mailing address

12110 NE MIAMI CT
NORTH MIAMI FL
33161-5354
US

V. Phone/Fax

Practice location:
  • Phone: 305-685-3796
  • Fax:
Mailing address:
  • Phone: 305-685-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: