=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740898253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANO HEALTH NEVADA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2020
-----------------------------------------------------
Last Update Date | 08/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3265 E TROPICANA AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-7386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 965-514-9360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9725 NW 117TH AVE STE 200
-----------------------------------------------------
City | MEDLEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-514-9360
-----------------------------------------------------
Fax | 954-432-5060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARLOW HERNANDEZ
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 954-514-9360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------