Provider Demographics
NPI:1033445069
Name:ROA-LICEA MD, PA
Entity Type:Organization
Organization Name:ROA-LICEA MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-564-2584
Mailing Address - Street 1:1321 NW 14TH ST
Mailing Address - Street 2:SUITE 601
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1673
Mailing Address - Country:US
Mailing Address - Phone:305-545-4980
Mailing Address - Fax:305-669-9820
Practice Address - Street 1:1321 NW 14TH STREET
Practice Address - Street 2:SUITE 601
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1659
Practice Address - Country:US
Practice Address - Phone:305-545-4980
Practice Address - Fax:305-669-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty