=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427326800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH FLORIDA ADHD CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17901 NW 5TH ST STE 103
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-392-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11341 NW 50TH TER
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-3545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-392-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARISELA CARMEN JAQUEZ-GUTIERREZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 305-392-6784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | ME70979
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------