=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215299276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURE COAST SWALLOWING DIAGNOSTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2012
-----------------------------------------------------
Last Update Date | 06/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 JOY HAVEN DR
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-249-1693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 JOY HAVEN DR
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-249-1693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL CHRISTOPHER GAUGHRAN
-----------------------------------------------------
Credential | M.S. CCC-SLP
-----------------------------------------------------
Telephone | 954-249-1693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA 7547
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------