Healthcare Provider Details

I. General information

NPI: 1134952617
Provider Name (Legal Business Name): MANUEL ANTONIO CISNEROS SR. OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 PALM BEACH LAKES BLVD STE 212
WEST PALM BEACH FL
33409-3411
US

IV. Provider business mailing address

2260 PALM BEACH LAKES BLVD STE 212
WEST PALM BEACH FL
33409-3411
US

V. Phone/Fax

Practice location:
  • Phone: 561-376-9305
  • Fax: 561-576-9307
Mailing address:
  • Phone: 561-376-9305
  • Fax: 561-576-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number299996179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: