Basic Information
| Provider Information | |||||||||
| NPI: | 1154807501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHORQUEZ | ||||||||
| FirstName: | FERNANDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25375 SW 202ND AVE | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330311654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863562424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2018 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-55279 | 01 | FL | BACB REGISTRATION BOARD | OTHER | 021357000 | 05 | FL | MEDICAID |