Provider Demographics
NPI:1912340506
Name:MORALES, JUAN CARLOS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:MORALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4007
Mailing Address - Country:US
Mailing Address - Phone:786-600-8679
Mailing Address - Fax:786-362-6157
Practice Address - Street 1:158 W 10TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4007
Practice Address - Country:US
Practice Address - Phone:786-600-8679
Practice Address - Fax:786-362-6157
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL76793104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003908000Medicaid