Healthcare Provider Details

I. General information

NPI: 1023905304
Provider Name (Legal Business Name): GINO CUELLO GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

915 SONESTA AVE NE
PALM BAY FL
32905-6339
US

IV. Provider business mailing address

915 SONESTA AVE NE
PALM BAY FL
32905-6339
US

V. Phone/Fax

Practice location:
  • Phone: 321-302-0840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number25-287
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: