=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629316070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BANYAN2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2013
-----------------------------------------------------
Last Update Date | 01/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6175 NW 153RD ST SUITE 332
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-663-5696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6619 S DIXIE HWY SUITE 229
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-7919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JUSTIN NEWMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-663-5696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------