Provider Demographics
NPI:1124205760
Name:ROSA MARIA PORTELA PA
Entity Type:Organization
Organization Name:ROSA MARIA PORTELA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:PORTELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-925-0141
Mailing Address - Street 1:6382 NW 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1645
Mailing Address - Country:US
Mailing Address - Phone:305-925-0141
Mailing Address - Fax:
Practice Address - Street 1:6382 NW 97TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-1645
Practice Address - Country:US
Practice Address - Phone:305-925-0141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K2938Medicare PIN