=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457713976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOMINGDALE ACUPUNCTURE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10015 PARK PLACE AVE
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33578-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-341-2200
-----------------------------------------------------
Fax | 801-469-0016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10419 KANKAKEE LN
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33578-8302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-341-2200
-----------------------------------------------------
Fax | 801-469-0016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GUILLERMO CACERES
-----------------------------------------------------
Credential | LAC, AP
-----------------------------------------------------
Telephone | 813-341-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP1469
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------