1134410079 NPI number — MRS. REGLA TRUJILLO CRT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134410079 NPI number — MRS. REGLA TRUJILLO CRT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRUJILLO
Provider First Name:
REGLA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134410079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11422 SW 73RD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33173-2692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-457-7784
Provider Business Mailing Address Fax Number:
786-360-4310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7282 SW 114TH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33173-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-457-7784
Provider Business Practice Location Address Fax Number:
786-360-4310
Provider Enumeration Date:
04/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 247100000X , with the licence number:  CRT 58464 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CRT 58464 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF QUALITY ASSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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