Provider Demographics
NPI:1821471962
Name:BREATH OF LIFE DIAGNOSTICS
Entity Type:Organization
Organization Name:BREATH OF LIFE DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-361-0755
Mailing Address - Street 1:3505 PROGRESS LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6519
Mailing Address - Country:US
Mailing Address - Phone:407-892-8925
Mailing Address - Fax:407-892-8926
Practice Address - Street 1:3505 PROGRESS LN
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6519
Practice Address - Country:US
Practice Address - Phone:407-892-8925
Practice Address - Fax:407-892-8926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL380652261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG41196Medicare UPIN