MEDICARE: MIDERKIS MENEDEZ

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	BACB596169	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528643574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIDERKIS MENEDEZ

Provider Business Mailing Address
First Line	:	4961 NW 179TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-3243
Country	:	US
Telephone Number	:	786-660-2482
Fax Number	:

Provider Business Practice Location Address
First Line	:	4961 NW 179TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-3243
Country	:	US
Telephone Number	:	786-660-2482
Fax Number	:

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

Provider Enumeration Date	:	03/11/2021
Last Update Date	:	03/11/2021

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Directions to “ MIDERKIS MENEDEZ ” Practice Location

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