=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790586105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YENI DETRINIDAD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2025
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6225 E STATE ROAD 64
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34208-6244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-708-2817
-----------------------------------------------------
Fax | 941-708-2819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6307 114TH AVE E
-----------------------------------------------------
City | PARRISH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34219-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-450-7464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO7143
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------