Basic Information
| Provider Information | |||||||||
| NPI: | 1093323628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | CLEIDY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E 33RD ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330133237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7868301155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1495 N PARK DR | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333263215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543562878 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-120494 | FL | Y |
No ID Information.