=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356011175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LPR PROFESSIONAL HEALTH CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2021
-----------------------------------------------------
Last Update Date | 09/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1518 NE VAN LOON LN
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33909-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-597-4260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1518 NE VAN LOON LN
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33909-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-597-4260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | LILLIAM PEREZ RODRIGUEZ
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 786-597-4260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------