=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053956821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. MARCELO JALDIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2019
-----------------------------------------------------
Last Update Date | 08/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4125 HUNTERS PARK LN STE 117
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-7615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-930-1678
-----------------------------------------------------
Fax | 863-353-6145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6202 SOLSTICE LOOP
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-0062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-929-2831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH12962
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------