Provider Demographics
NPI:1093301012
Name:REBUSTILLO, FERNANDO RENE JR
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:RENE
Last Name:REBUSTILLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15730 SW 99TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1668
Mailing Address - Country:US
Mailing Address - Phone:305-731-1397
Mailing Address - Fax:
Practice Address - Street 1:5931 NW 173RD DR UNIT 10
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5107
Practice Address - Country:US
Practice Address - Phone:305-731-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician