Healthcare Provider Details

I. General information

NPI: 1164272688
Provider Name (Legal Business Name): BRIAN ETHEN BARBOSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 NE 123RD ST
NORTH MIAMI FL
33181-2902
US

IV. Provider business mailing address

8840 NW 99TH PATH
DORAL FL
33178-2762
US

V. Phone/Fax

Practice location:
  • Phone: 305-967-8976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: