Basic Information
Provider Information
NPI: 1114577228
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VICIANA
FirstName: JULIANA
MiddleName: SOFIA
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7705 SW 188TH TER
Address2:  
City: CUTLER BAY
State: FL
PostalCode: 331578045
CountryCode: US
TelephoneNumber: 7862669945
FaxNumber:  
Practice Location
Address1: 10300 SW 72ND ST STE 114
Address2:  
City: MIAMI
State: FL
PostalCode: 331733038
CountryCode: US
TelephoneNumber: 3055085580
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/19/2019
LastUpdateDate: 09/20/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-19-98232FLY    

No ID Information.


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