1114649431 NPI number — EIMYS GONZALEZ DE LA ROSA

Table of content: EIMYS GONZALEZ DE LA ROSA (NPI 1114649431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114649431 NPI number — EIMYS GONZALEZ DE LA ROSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ DE LA ROSA
Provider First Name:
EIMYS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1114649431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13755 SW 26TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027-3961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-861-4408
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 NW 82ND AVE APT 216
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:
33126-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-861-4408
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2022

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116418500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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