=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619217809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUAN R LEBRON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2013
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E FLORIDA AVE
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-8301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5965 S TROPICAL TRL
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-7122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-373-3412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUAN R LEBRON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 315-373-3412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME115079
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------