Basic Information
| Provider Information | |||||||||
| NPI: | 1891387478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14900 NW 79TH CT STE 101 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058210502 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14900 NW 79TH CT STE 101 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058210502 | ||||||||
| FaxNumber: | 3053625209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2021 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 30831 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.