=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164877833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZION HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2016
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11389 W FLAGLER ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-1185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-886-3400
-----------------------------------------------------
Fax | 786-886-3401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1470 NW 107TH AVE SUITE G
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-886-3400
-----------------------------------------------------
Fax | 305-594-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JULIETTA MARRERO
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 786-886-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | MH 11022
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------