Basic Information
Provider Information
NPI: 1548918295
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GUTIERREZ
FirstName: BIENVENIDA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7515 SW 152ND AVE APT A202
Address2:  
City: MIAMI
State: FL
PostalCode: 331933267
CountryCode: US
TelephoneNumber: 7864062020
FaxNumber:  
Practice Location
Address1: 15790 SW 307TH ST
Address2:  
City: HOMESTEAD
State: FL
PostalCode: 330334200
CountryCode: US
TelephoneNumber: 3052450270
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/11/2022
LastUpdateDate: 03/11/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/11/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-20-124427FLY    

No ID Information.


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