Provider Demographics
NPI:1184471864
Name:PANTOJA MAINEGRA, EIDA DAYANET
Entity type:Individual
Prefix:
First Name:EIDA
Middle Name:DAYANET
Last Name:PANTOJA MAINEGRA
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 1:12454 SW 197TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4987
Mailing Address - Country:US
Mailing Address - Phone:305-986-3911
Mailing Address - Fax:
Practice Address - Street 1:12454 SW 197TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-4987
Practice Address - Country:US
Practice Address - Phone:305-986-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician