=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265207930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONACO MEDICAL SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2023
-----------------------------------------------------
Last Update Date | 11/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2930 NE 2ND CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-252-2401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2930 NE 2ND CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-252-2401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEANNETTE BARRUETA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-252-2401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------