MEDICARE: ALFONSO PROFESSIONAL MEDICAL CTR

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	261QP2000X	Physical Therapy Clinic/Center	MA 42956	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA 42956	OTHER	FL	STATE OF FLORIDA DEPT OF HEALTH

General Provider Information

NPI Number	:	1518191576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALFONSO PROFESSIONAL MEDICAL CTR

Provider Business Mailing Address
First Line	:	11180 W FLAGLER ST
Second Line	:	STE 13
City	:	MIAMI
State	:	FL
Zip	:	33174-1216
Country	:	US
Telephone Number	:	305-480-8473
Fax Number	:	305-480-8472

Provider Business Practice Location Address
First Line	:	11180 W FLAGLER STREET
Second Line	:	STE 13
City	:	MIAMI
State	:	FL
Zip	:	33174-1215
Country	:	US
Telephone Number	:	305-480-8473
Fax Number	:	305-480-8472

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JUAN CARLOS ALFONSO
Credential	:	MA
Telephone Number	:	305-480-8473

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	05/06/2009

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Directions to “ALFONSO PROFESSIONAL MEDICAL CTR ” Practice Location

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