=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073004214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIEVES MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2018
-----------------------------------------------------
Last Update Date | 06/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1140 W 50TH ST STE 207
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-540-2363
-----------------------------------------------------
Fax | 305-456-3070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1140 W 50TH ST STE 207
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-540-2363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERESA RIVERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-972-0392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------