1003422908 NPI number — FREDY MANUEL FONSECA AVILA SR. RBT

Table of content: FREDY MANUEL FONSECA AVILA SR. RBT (NPI 1003422908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003422908 NPI number — FREDY MANUEL FONSECA AVILA SR. RBT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONSECA AVILA
Provider First Name:
FREDY
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
RBT
Provider Gender Code:
M

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:
1003422908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2601 NW 16TH STREET RD APT 236
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:
33125-1482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-865-1297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8245 NW 36TH ST STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33166-6636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-594-5658
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2020

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: 106S00000X , with the licence number:  RBT-20-118657 , 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)





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