=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225445604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI LAKES REHAB & SPORTS THERAPY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2014
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6500 COW PEN RD SUITE 101
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-820-6997
-----------------------------------------------------
Fax | 305-820-6998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6500 COW PEN RD SUITE 101
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-820-6997
-----------------------------------------------------
Fax | 305-820-6998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | YOLANDA M SOTTER
-----------------------------------------------------
Credential | PHYSICAL THERAPIST
-----------------------------------------------------
Telephone | 305-820-6997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------