=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043722895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMEDICAL CENTERS MIAMI CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2017
-----------------------------------------------------
Last Update Date | 11/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9100 SW 24TH ST STE 6
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-967-8610
-----------------------------------------------------
Fax | 786-431-1909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9100 SW 24TH ST STE 6
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-967-8610
-----------------------------------------------------
Fax | 786-431-1909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RENE CASANOVA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-967-8610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | ME78770
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------