MEDICARE: ADA IRIS GUMILA PORTUONDO

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-24-322720	FL

General Provider Information

NPI Number	:	1720820152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADA IRIS GUMILA PORTUONDO

Provider Business Mailing Address
First Line	:	13715 SW 30TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6606
Country	:	US
Telephone Number	:	786-561-9105
Fax Number	:

Provider Business Practice Location Address
First Line	:	13715 SW 30TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6606
Country	:	US
Telephone Number	:	786-561-9105
Fax Number	:

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

Provider Enumeration Date	:	06/07/2024
Last Update Date	:	06/07/2024

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Directions to “ ADA IRIS GUMILA PORTUONDO ” Practice Location

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