MEDICARE: JULIO RENE GORT 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	RBT-23-315850	FL

General Provider Information

NPI Number	:	1164291746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIO RENE GORT FERNANDEZ

Provider Business Mailing Address
First Line	:	6460 PARK ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-4123
Country	:	US
Telephone Number	:	786-449-7263
Fax Number	:

Provider Business Practice Location Address
First Line	:	6460 PARK ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-4123
Country	:	US
Telephone Number	:	786-449-7263
Fax Number	:

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

Provider Enumeration Date	:	12/25/2023
Last Update Date	:	12/25/2023

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