=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184209421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSEIDON DIAGNOSTICS CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2021
-----------------------------------------------------
Last Update Date | 03/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2065 NE 163RD ST
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33162-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-425-2272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4331 SW 132ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | HUASCAR RIJSSENBEEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-903-2303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------