MEDICARE: MILEYDIS MOLLERSTROM

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	225200000X	Physical Therapy Assistant	PTA26606	FL
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1467806901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILEYDIS MOLLERSTROM

Provider Business Mailing Address
First Line	:	6107 NW 183RD LN
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-5623
Country	:	US
Telephone Number	:	786-624-0901
Fax Number	:

Provider Business Practice Location Address
First Line	:	6107 NW 183RD LN
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-5623
Country	:	US
Telephone Number	:	786-624-0901
Fax Number	:

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

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	03/03/2017

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Directions to “ MILEYDIS MOLLERSTROM ” Practice Location

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