Provider Demographics
NPI:1700299450
Name:LAO, YUDITH
Entity Type:Individual
Prefix:
First Name:YUDITH
Middle Name:
Last Name:LAO
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 1:22712 SW 103RD CT
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1778
Mailing Address - Country:US
Mailing Address - Phone:305-254-6139
Mailing Address - Fax:305-254-6139
Practice Address - Street 1:22712 SW 103RD CT
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1778
Practice Address - Country:US
Practice Address - Phone:305-254-6139
Practice Address - Fax:305-254-6139
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10867310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008445700Medicaid