MEDICARE: KIDS FITNESS FOR LIFE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063811602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS FITNESS FOR LIFE LLC

Provider Business Mailing Address
First Line	:	10271 SW 72ND ST
Second Line	:	UNIT D101
City	:	MIAMI
State	:	FL
Zip	:	33173-3024
Country	:	US
Telephone Number	:	786-866-9264
Fax Number	:	786-866-9265

Provider Business Practice Location Address
First Line	:	10271 SW 72ND ST
Second Line	:	UNIT D101
City	:	MIAMI
State	:	FL
Zip	:	33173-3024
Country	:	US
Telephone Number	:	786-866-9264
Fax Number	:	786-866-9265

Authorized Official
Title or Position	:	OWNER
Name	:	DR. YAMILE MARLES
Credential	:	MD
Telephone Number	:	786-866-9264

Provider Enumeration Date	:	08/20/2014
Last Update Date	:	08/20/2014

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