=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629899984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENATO CARLO SOTELO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21000 NE 28TH AVE STE 305
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-933-5993
-----------------------------------------------------
Fax | 305-993-9415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9960 NW 116TH WAY STE 13
-----------------------------------------------------
City | MEDLEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-1175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-924-1311
-----------------------------------------------------
Fax | 786-924-1313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2024084788
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11036267
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------