Basic Information
Provider Information | |||||||||
NPI: | 1275961872 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BANYAN HEALTH SYSTEMS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 310 FONTAINEBLEAU BLVD APT 505 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331725726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3057817265 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11031 NE 6TH AVE | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331617182 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7862939544 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2013 | ||||||||
LastUpdateDate: | 10/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOPEZ | ||||||||
AuthorizedOfficialFirstName: | ALEJANDRO | ||||||||
AuthorizedOfficialMiddleName: | JAVIER | ||||||||
AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 3057817265 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | M.S.W. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.