=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366031692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXINE MED CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13750 SW 285TH TER
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33033-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-326-3426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13750 SW 285TH TER
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33033-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-326-3426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | JULIO PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-326-3426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------