=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447282900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DORAL MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 08/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3750 W 16TH AVE STE 108
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-512-0327
-----------------------------------------------------
Fax | 305-512-0328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3750 W 16TH AVE STE 108
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-512-0327
-----------------------------------------------------
Fax | 305-512-0328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANTONIO CANTOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-512-0327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | HCC 6046
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------