Provider Demographics
NPI:1194440396
Name:NIETO, MICHAEL (PRESIDENT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NIETO
Suffix:
Gender:M
Credentials:PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4608
Mailing Address - Country:US
Mailing Address - Phone:786-404-3753
Mailing Address - Fax:786-404-3735
Practice Address - Street 1:156 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4608
Practice Address - Country:US
Practice Address - Phone:786-404-3753
Practice Address - Fax:786-404-3735
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL987150Medicaid