Healthcare Provider Details

I. General information

NPI: 1386314938
Provider Name (Legal Business Name): JOERIK ACEVEDO MEDINA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 MENTA ST STE 105
ORLANDO FL
32837-7540
US

IV. Provider business mailing address

12200 MENTA ST STE 105
ORLANDO FL
32837-7540
US

V. Phone/Fax

Practice location:
  • Phone: 407-757-2257
  • Fax: 407-845-1102
Mailing address:
  • Phone: 407-757-2257
  • Fax: 407-845-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number9376564
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: