=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467872317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2014
-----------------------------------------------------
Last Update Date | 04/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6955 NW 77TH AVE STE 306
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-206-1603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6955 NW 77TH AVE STE 306
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-206-1603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. KALY CASTELLANOS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 305-206-1603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | ME14277
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------