Healthcare Provider Details

I. General information

NPI: 1548055973
Provider Name (Legal Business Name): MIA N BULSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CENTRAL FLORIDA BLVD
ORLANDO FL
32816-8005
US

IV. Provider business mailing address

8810 NORMANS CAY DR UNIT 9105
ORLANDO FL
32817-2215
US

V. Phone/Fax

Practice location:
  • Phone: 407-823-2000
  • Fax:
Mailing address:
  • Phone: 813-503-3425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: