=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457775868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSOL CLINICAL RESEARCH CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2014
-----------------------------------------------------
Last Update Date | 02/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3280 TAMIAMI TRL SUITE 54 A
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-623-9744
-----------------------------------------------------
Fax | 941-623-9743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3280 TAMIAMI TRL SUITE 54 A
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-623-9744
-----------------------------------------------------
Fax | 941-623-9743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MRS. MARIA FILOMENA VASCONCELOS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 941-623-9744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1100X
-----------------------------------------------------
Taxonomy Name | Research Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------