Provider Demographics
NPI:1720489677
Name:PRESTIGE THERAPY
Entity Type:Organization
Organization Name:PRESTIGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MA42961
Authorized Official - Phone:305-381-5150
Mailing Address - Street 1:951 SW 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2406
Mailing Address - Country:US
Mailing Address - Phone:305-381-5150
Mailing Address - Fax:305-381-5150
Practice Address - Street 1:951 SW 122ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2406
Practice Address - Country:US
Practice Address - Phone:305-381-5150
Practice Address - Fax:305-381-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42961261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center