Provider Demographics
NPI:1861988016
Name:VICIOSO MEDICAL AND ADDICTION SERVICES LLC
Entity type:Organization
Organization Name:VICIOSO MEDICAL AND ADDICTION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:VICIOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-808-5915
Mailing Address - Street 1:5729 LIVE OAK TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6377
Mailing Address - Country:US
Mailing Address - Phone:646-808-5915
Mailing Address - Fax:
Practice Address - Street 1:7261 SHERIDAN ST STE 100D
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2708
Practice Address - Country:US
Practice Address - Phone:954-534-7696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty