Healthcare Provider Details

I. General information

NPI: 1215744891
Provider Name (Legal Business Name): JUAN NABONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 WEMBLEYCROSS WAY
ORLANDO FL
32828-7964
US

IV. Provider business mailing address

2605 WEMBLEYCROSS WAY
ORLANDO FL
32828-7964
US

V. Phone/Fax

Practice location:
  • Phone: 407-810-1585
  • Fax:
Mailing address:
  • Phone: 407-810-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number3101-1116740
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: