Provider Demographics
NPI:1407214604
Name:RESTAURANTE UNIVERSAL DEL PUEBLO
Entity Type:Organization
Organization Name:RESTAURANTE UNIVERSAL DEL PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:EDITH
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:01/24/1962
Authorized Official - Phone:786-487-8104
Mailing Address - Street 1:2072 OPA LOCKA BLVD
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-4228
Mailing Address - Country:US
Mailing Address - Phone:786-487-8104
Mailing Address - Fax:786-592-1504
Practice Address - Street 1:2072 OPA LOCKA BLVD
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-4228
Practice Address - Country:US
Practice Address - Phone:786-487-8104
Practice Address - Fax:786-592-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid