Provider Demographics
NPI:1003371774
Name:DAVALOS HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:DAVALOS HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVALOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-619-1095
Mailing Address - Street 1:11760 SW 40TH ST STE 335
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3595
Mailing Address - Country:US
Mailing Address - Phone:305-588-7117
Mailing Address - Fax:305-227-3151
Practice Address - Street 1:11760 SW 40TH ST STE 335
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3595
Practice Address - Country:US
Practice Address - Phone:305-588-7117
Practice Address - Fax:305-227-3151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020900200Medicaid