=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124614383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY KIDS LIFE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 12/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15668 SW 10TH LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33194-2755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-406-3504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15668 SW 10TH LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33194-2755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-406-3504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YUNIT JUANTORENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-406-3504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------