=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366571762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. AMIR LIZARRAGA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 HERITAGE CIR
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-230-9831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 HERITAGE CIR
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-230-9831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | L06000104299
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------