=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356080923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESTER OMAR CARVAJALES DIEGUEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2022
-----------------------------------------------------
Last Update Date | 06/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1893 NE MIAMI GARDENS DR
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-5035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-682-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6420 SW 139TH AVENUE RD APT 302
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-970-9301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 31913
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------