=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336702109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE WOMENS CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2019
-----------------------------------------------------
Last Update Date | 04/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11319 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11319 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JOHANNES WIJNMAALEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------