=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144509506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FICO THERAPIES CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2011
-----------------------------------------------------
Last Update Date | 10/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1774 NW 42 ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-326-6180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1774 NW 42ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33142-4867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-326-6180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | P
-----------------------------------------------------
Name | FEDERICO FERNANDO SARIOL CRESPO
-----------------------------------------------------
Credential | MAMA 62868
-----------------------------------------------------
Telephone | 786-326-6180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | MA62868
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------