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General NPI Number Information
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NPI Number | 1619417102
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Entity Type | Organization
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Legal Business Name | MIAMI LICE LLC
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Dates
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Enumeration Date | 03/02/2017
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Last Update Date | 03/02/2017
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Provider Practice Location Address
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Address Line | 1801 CORAL WAY SUITE #320
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City | MIAMI
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State | FL
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Zip | 33145-2790
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Country | US
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Telephone | 305-907-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 CORAL WAY SUITE #320
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City | MIAMI
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State | FL
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Zip | 33145-2790
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Country | US
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Telephone | 305-907-2121
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | HEATHER C WILSON O'CONNOR
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Credential |
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Telephone | 305-389-4430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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