MEDICARE: THE GYMNASTICS ACADEMY, CO.

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1114399359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GYMNASTICS ACADEMY, CO.

Provider Business Mailing Address
First Line	:	15660 SW 72ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-1923
Country	:	US
Telephone Number	:	305-386-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	15660 SW 72ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-1923
Country	:	US
Telephone Number	:	305-386-8500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VARINIA OLIVEIRA
Credential	:
Telephone Number	:	786-291-2028

Provider Enumeration Date	:	10/27/2015
Last Update Date	:	10/27/2015

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