=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487595211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KC&LB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2026
-----------------------------------------------------
Last Update Date | 04/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16123 KINGSMOOR WAY
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-350-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16123 KINGSMOOR WAY
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-350-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MIREILIS CASUSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-350-6784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------