=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497549455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVE AND ENERGY MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2025
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4995 NW 72ND AVE STE 102
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-956-1889
-----------------------------------------------------
Fax | 305-392-0737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2337 W 76TH ST STE 101-B
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-956-1889
-----------------------------------------------------
Fax | 305-392-0737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NEYDA TANQUERO DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-956-1889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------