Provider Demographics
NPI:1871106658
Name:BENCOMO, MARIO ABUNDIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ABUNDIO
Last Name:BENCOMO
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 1:350 W PARK DR APT 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3943
Mailing Address - Country:US
Mailing Address - Phone:786-399-3890
Mailing Address - Fax:
Practice Address - Street 1:18255 HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-5564
Practice Address - Country:US
Practice Address - Phone:786-845-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9241274163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN9241274OtherREGISTER NURSE