=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225589849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI BLUE HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2016
-----------------------------------------------------
Last Update Date | 03/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12001 SW 128TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-821-3666
-----------------------------------------------------
Fax | 305-821-3666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7150 W 20TH AVE
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-5529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-821-3999
-----------------------------------------------------
Fax | 305-821-3666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHISTIAN ALEXANDRA MEYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-854-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------