=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285068924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCESS MEDICAL CENTER, 'LLC'.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2013
-----------------------------------------------------
Last Update Date | 08/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5801 HALLANDALE BEACH BLVD STE 200
-----------------------------------------------------
City | WEST PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-5243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-748-9310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 HALLANDALE BEACH BLVD STE 200
-----------------------------------------------------
City | WEST PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-5243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-748-9310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | GUYLENE BERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-748-9310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------