=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497004238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAMONT OF GABLES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2012
-----------------------------------------------------
Last Update Date | 09/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 PONCE DE LEON SUITE 85
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-305-0218
-----------------------------------------------------
Fax | 305-437-8033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 PONCE DE LEON SUITE 85
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-305-0218
-----------------------------------------------------
Fax | 305-437-8033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSE FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-305-0218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------