=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417385782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOI CENTER & SPA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2013
-----------------------------------------------------
Last Update Date | 10/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7811 CORAL WAY SUITE 103
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-6540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-237-9309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2720 SW 139TH PL
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ARELYS MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-237-9309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------