=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518310549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IVELISSE MEDINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2016
-----------------------------------------------------
Last Update Date | 07/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2275 FORTUNE RD
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34744-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-348-2060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12087 JEWEL FISH LN
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32827-7141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-479-6479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IVELISSE MEDINA
-----------------------------------------------------
Credential | SLPA
-----------------------------------------------------
Telephone | 787-479-6479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 2200
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------