=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104922715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOS OF NORTH SHORE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9380 NW 7TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33150-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-759-8711
-----------------------------------------------------
Fax | 305-757-8860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9380 NW 7TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33150-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-759-8711
-----------------------------------------------------
Fax | 305-757-8860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JORGE R HERNANDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-868-1830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1372096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------