Provider Demographics
NPI:1346859360
Name:BANDOMO VILAS, OSBEL I
Entity Type:Individual
Prefix:
First Name:OSBEL
Middle Name:I
Last Name:BANDOMO VILAS
Suffix:
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 1:1026 NW 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3946
Mailing Address - Country:US
Mailing Address - Phone:786-717-8244
Mailing Address - Fax:
Practice Address - Street 1:1026 NW 33RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3946
Practice Address - Country:US
Practice Address - Phone:786-717-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20121450106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician