=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386063592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. BORIS KAWLICHE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N PARSONS AVE SUITE 107A
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-5880
-----------------------------------------------------
Fax | 813-681-5958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N PARSONS AVE SUITE 107A
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-5880
-----------------------------------------------------
Fax | 813-681-5958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BORIS L. KAWLICHE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-681-5880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME66500
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------