=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104458082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCARE THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2020
-----------------------------------------------------
Last Update Date | 02/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SW 104TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-473-7257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 SW 104TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-447-3725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | RAQUEL VARON
-----------------------------------------------------
Credential | MS, SLP
-----------------------------------------------------
Telephone | 786-447-3725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------