=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629303375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL TRAVEL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2009
-----------------------------------------------------
Last Update Date | 10/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6280 SW 72ND ST SUITE 607
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-4827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-668-0075
-----------------------------------------------------
Fax | 305-668-6299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6400 SW 122ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156-5549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-668-0075
-----------------------------------------------------
Fax | 305-668-6299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. KUNJANA MAVUNDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-668-0075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | ME0047855
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------