Provider Demographics
NPI:1609424811
Name:MACIAS ECHAZABAL, AILIC (BS)
Entity Type:Individual
Prefix:
First Name:AILIC
Middle Name:
Last Name:MACIAS ECHAZABAL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8462 NW 103RD ST APT 108
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4684
Mailing Address - Country:US
Mailing Address - Phone:305-834-6978
Mailing Address - Fax:
Practice Address - Street 1:10550 NW 77TH CT STE 313-314
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-7084
Practice Address - Country:US
Practice Address - Phone:305-825-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator