=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205128337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAKURA MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2011
-----------------------------------------------------
Last Update Date | 05/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2721 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-559-1214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2721 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-559-1214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | JORGE DIAS TABOADA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-559-1214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------