=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497155170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA DYNAMIC THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2014
-----------------------------------------------------
Last Update Date | 08/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 949 SW 122ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33184-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-741-8785
-----------------------------------------------------
Fax | 305-381-1421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 949 SW 122ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33184-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-741-8785
-----------------------------------------------------
Fax | 305-381-1421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIA DEL CARMEN BURUNAT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-741-8785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | ME81400
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------