Provider Demographics
NPI:1871871889
Name:MADRUGA, ORELVYS
Entity type:Individual
Prefix:
First Name:ORELVYS
Middle Name:
Last Name:MADRUGA
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 1:6962 SW 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1039
Mailing Address - Country:US
Mailing Address - Phone:786-294-8984
Mailing Address - Fax:
Practice Address - Street 1:6962 SW 148TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1039
Practice Address - Country:US
Practice Address - Phone:786-294-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 60387225700000X
FLRBT-20-118008106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty