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General NPI Number Information
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NPI Number | 1942505243
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Entity Type | Organization
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Legal Business Name | MIBASO
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Dates
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Enumeration Date | 01/18/2011
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Last Update Date | 01/18/2011
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Provider Practice Location Address
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Address Line | 1045 KANE CONCOURSE 214
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City | BAY HARBOR ISLANDS
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State | FL
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Zip | 33154-2119
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Country | US
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Telephone | 786-537-0771
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Fax |
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Provider Business Mailing Address
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Address Line | 1045 KANE CONCOURSE 214
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City | BAY HARBOR ISLANDS
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State | FL
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Zip | 33154-2119
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Country | US
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Telephone | 786-537-0771
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. AHUVA GAMLIEL
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Credential | AP
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Telephone | 786-537-0771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | AP2313
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License Number State | FL
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