Healthcare Provider Details

I. General information

NPI: 1578879375
Provider Name (Legal Business Name): 125TH STREET NM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 125TH ST
NORTH MIAMI FL
33161-4718
US

IV. Provider business mailing address

505 NE 125TH ST
NORTH MIAMI FL
33161-4718
US

V. Phone/Fax

Practice location:
  • Phone: 786-235-7240
  • Fax: 786-235-7241
Mailing address:
  • Phone: 786-235-7240
  • Fax: 786-235-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPMC 20
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberPMC 20
License Number StateFL

VIII. Authorized Official

Name: MR. IGOR NIZNIK
Title or Position: PRESIDENT
Credential:
Phone: 786-235-7240