=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265824387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDYCO DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2015
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 BISCAYNE BLVD STE 301
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-200-2566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3915 BISCAYNE BLVD STE 301
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-200-2566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | ISABEL PANESSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-200-2566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | LC11484
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | LC11484
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 247100000X
-----------------------------------------------------
Taxonomy Name | Radiologic Technologist
-----------------------------------------------------
License Number | LC11484
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number | LC11484
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | LC11484
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------