=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194149740
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENATO LASAM MIGUEL JR. PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2014
-----------------------------------------------------
Last Update Date | 02/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16089 POPPYSEED CIR UNIT 2008
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-699-3714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16089 POPPYSEED CIRCLE, SUITE 2008
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-699-3714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT29008
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------