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General NPI Number Information
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NPI Number | 1679844336
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Entity Type | Organization
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Legal Business Name | ST JUDE PROFESSIONAL SERVICE INC
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Dates
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Enumeration Date | 01/25/2012
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Last Update Date | 03/09/2012
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Provider Practice Location Address
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Address Line | 2387 W 68TH ST 504
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City | HIALEAH
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State | FL
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Zip | 33016-6889
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Country | US
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Telephone | 786-360-1452
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Fax | 786-360-1877
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Provider Business Mailing Address
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Address Line | 2387 W 68TH ST 504
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City | HIALEAH
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State | FL
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Zip | 33016-6889
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Country | US
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Telephone | 786-360-1452
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Fax | 786-360-1877
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Authorized Official
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Title or Position | PRESIDENT
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Name | OSVALDO PINEIRO SR.
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Credential | LMT
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Telephone | 786-360-1452
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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 | 10256
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License Number State | FL
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