=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205087442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARINA'S MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2008
-----------------------------------------------------
Last Update Date | 10/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5591 CORTEZ RD W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34210-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-795-4206
-----------------------------------------------------
Fax | 941-792-1568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14520
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34280-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-795-4206
-----------------------------------------------------
Fax | 941-792-1568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. ZORAYA NARVAEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-795-4206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------