=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578542619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CADC CORP - MIRACLE REHAB CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2006
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7944 SW 8TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-266-4048
-----------------------------------------------------
Fax | 305-266-4049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7944 SW 8TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-266-4048
-----------------------------------------------------
Fax | 305-266-4049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. LUIS A IBANEZ
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 305-266-4048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT107
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------