=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346809357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERED LIVING COMMUNITY CENTER CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2019
-----------------------------------------------------
Last Update Date | 02/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 SW 57TH AVE APT 704
-----------------------------------------------------
City | WEST MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-547-1568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 SW 57TH AVE APT 304
-----------------------------------------------------
City | WEST MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-5087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-547-1568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MAIKEL ROQUE RUANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-547-1568
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------