=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134502719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUAN YIN MEDICAL CENTER, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2015
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 NE 97TH ST
-----------------------------------------------------
City | MIAMI SHORES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33138-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-758-7011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 NE 97TH ST
-----------------------------------------------------
City | MIAMI SHORES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33138-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-758-7011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT GASTON JR.
-----------------------------------------------------
Credential | O.M.D., A.P.
-----------------------------------------------------
Telephone | 305-758-7011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP-1020
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------