Provider Demographics
NPI:1093373409
Name:PROFORM MD LLC
Entity Type:Organization
Organization Name:PROFORM MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RODRIGO
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-517-4577
Mailing Address - Street 1:8525 SW 92ND ST STE D17
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7378
Mailing Address - Country:US
Mailing Address - Phone:786-517-4577
Mailing Address - Fax:786-364-7330
Practice Address - Street 1:8525 SW 92ND ST STE D17
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7378
Practice Address - Country:US
Practice Address - Phone:786-517-4577
Practice Address - Fax:786-364-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty