MEDICARE: MELANIO BRUCETA LLC

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	163W00000X	Registered Nurse

General Provider Information

NPI Number	:	1588240360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELANIO BRUCETA LLC

Provider Business Mailing Address
First Line	:	5731 PALM AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-2756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5731 PALM AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-2756
Country	:	US
Telephone Number	:	305-409-9192
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MELANIO BRUCETA
Credential	:	APRN
Telephone Number	:	305-409-9192

Provider Enumeration Date	:	03/22/2021
Last Update Date	:	03/22/2021

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