Provider Demographics
NPI:1851642185
Name:ULLOA, ALFREDO TALAY (LMT)
Entity Type:Individual
Prefix:PROF
First Name:ALFREDO
Middle Name:TALAY
Last Name:ULLOA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:PROF
Other - First Name:ALFREDO
Other - Middle Name:TALAY
Other - Last Name:ULLOA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2445 SW 18TH TER APT 109
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2236
Mailing Address - Country:US
Mailing Address - Phone:786-356-7208
Mailing Address - Fax:
Practice Address - Street 1:2445 SW 18 TH TERR
Practice Address - Street 2:APT 109
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2236
Practice Address - Country:US
Practice Address - Phone:786-356-7208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 61706172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker