MEDICARE: MR. JOSE ANTONIO FERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1023634326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE ANTONIO FERNANDEZ

Provider Business Mailing Address
First Line	:	3506 W 80TH ST UNIT 102
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-7502
Country	:	US
Telephone Number	:	305-433-0750
Fax Number	:

Provider Business Practice Location Address
First Line	:	3506 W 80TH ST UNIT 102
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-7502
Country	:	US
Telephone Number	:	305-433-0750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/29/2020

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