MEDICARE: FLOR DE MARIA MACAVILCA BS

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	171M00000X	Case Manager/Care Coordinator	CBHCMP102653	FL

General Provider Information

NPI Number	:	1295491090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FLOR DE MARIA MACAVILCA BS

Provider Business Mailing Address
First Line	:	930 NE 155TH ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-5310
Country	:	US
Telephone Number	:	786-267-2919
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 NE 155TH ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-5310
Country	:	US
Telephone Number	:	786-267-2919
Fax Number	:

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

Provider Enumeration Date	:	11/16/2021
Last Update Date	:	11/16/2021

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