=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205223054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELS FOR KIDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2015
-----------------------------------------------------
Last Update Date | 04/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 HONEY BLOSSOM DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-4866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-382-9045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 HONEY BLOSSOM DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-4866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-382-9045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSR/TCM
-----------------------------------------------------
Name | MR. ALBERTO E GROSSO ORTIZ
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 786-382-9045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------