=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326680968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAS MARIAS HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2019
-----------------------------------------------------
Last Update Date | 10/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15071 SW 49TH CT
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-200-1270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15071 SW 49TH CT
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-200-1270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA VIRGINIA GOMEZ PADRON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 786-200-1270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------