=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427433598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYLEY GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2015
-----------------------------------------------------
Last Update Date | 07/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5079 SW 103RD AVE
-----------------------------------------------------
City | COOPER CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-639-6635
-----------------------------------------------------
Fax | 954-252-4073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5079 SW 103RD AVE
-----------------------------------------------------
City | COOPER CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-639-6635
-----------------------------------------------------
Fax | 954-252-4073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. JIMMY NELSON OTERO
-----------------------------------------------------
Credential | SA-C
-----------------------------------------------------
Telephone | 954-534-4855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 15-345
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------