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General NPI Number Information
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NPI Number | 1023568318
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Entity Type | Organization
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Legal Business Name | PROHEALTH DORAL MEDICAL INC
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Dates
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Enumeration Date | 10/11/2016
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Last Update Date | 10/11/2016
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Provider Practice Location Address
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Address Line | 8247 NW 36TH ST
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City | DORAL
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State | FL
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Zip | 33166-6613
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Country | US
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Telephone | 786-422-4309
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Fax |
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Provider Business Mailing Address
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Address Line | 8247 NW 36TH ST
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City | DORAL
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State | FL
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Zip | 33166-6613
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. OTTO URDANETA
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Credential |
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Telephone | 786-422-4309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ME32388
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License Number State | FL
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