MEDICARE: PEDIATRIC GERIATRIC COMMUNICATIONS DISORDERS, INC

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1093111262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC GERIATRIC COMMUNICATIONS DISORDERS, INC

Provider Business Mailing Address
First Line	:	19845 NW 54TH PL
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-6156
Country	:	US
Telephone Number	:	786-506-4154
Fax Number	:	786-916-5858

Provider Business Practice Location Address
First Line	:	19845 NW 54TH PL
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-6156
Country	:	US
Telephone Number	:	786-506-4154
Fax Number	:	786-916-5858

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARLOS NAVAL PEREZ HENRIQUEZ
Credential	:	SLP
Telephone Number	:	786-506-4154

Provider Enumeration Date	:	11/14/2014
Last Update Date	:	11/14/2014

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