Provider Demographics
NPI:1922275346
Name:EUBANKS, TRENIECE
Entity Type:Individual
Prefix:
First Name:TRENIECE
Middle Name:
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:CENTRAL 300
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-6970
Mailing Address - Fax:305-585-7169
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:CENTRAL 300
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6970
Practice Address - Fax:305-585-7169
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME113166207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05477Medicaid