Provider Demographics
NPI:1225281611
Name:MIRO, LILLIAM (CNA #108987)
Entity Type:Individual
Prefix:
First Name:LILLIAM
Middle Name:
Last Name:MIRO
Suffix:
Gender:F
Credentials:CNA #108987
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 R O SMART DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625
Mailing Address - Country:US
Mailing Address - Phone:813-412-7744
Mailing Address - Fax:
Practice Address - Street 1:6706 R O SMART DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625
Practice Address - Country:US
Practice Address - Phone:813-412-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
687627796OtherMED. WEIBER AGENCY FOR PERSON WITH DISABILITIES
FL687627798Medicaid