Provider Demographics
NPI:1356939680
Name:BIOLIBRIUMPLLC
Entity type:Organization
Organization Name:BIOLIBRIUMPLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ITCHAQUEIRA
Authorized Official - Middle Name:BEATRIZ
Authorized Official - Last Name:FONTANEZ VENDRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RD/LDN
Authorized Official - Phone:863-258-7986
Mailing Address - Street 1:1675 POLO LAKE DR E APT 104
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 POLO LAKE DR E APT 104
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3112
Practice Address - Country:US
Practice Address - Phone:863-258-7986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
15048304OtherCAQH
1629664685OtherNPPES