=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003452251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELGADO EYE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2019
-----------------------------------------------------
Last Update Date | 11/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 NW 15TH ST
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-4266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-397-4636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10011 NW 4TH ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KARLA DELGADO
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 786-397-4636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------