=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407255136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH OFFICE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2014
-----------------------------------------------------
Last Update Date | 08/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 NW 79TH AVE SUITE 650
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-429-0325
-----------------------------------------------------
Fax | 786-364-1293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 NW 79TH AVE SUITE 650
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-429-0325
-----------------------------------------------------
Fax | 786-364-1293
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. OSORIO AIDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-429-0325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------