=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649700808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAKE GYN AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 N PARK BLVD STE 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-6900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-280-9616
-----------------------------------------------------
Fax | 817-722-6328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 71 PARK BLVD #100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-280-9616
-----------------------------------------------------
Fax | 817-722-6328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIRIAM M TORRES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-280-9616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 41197
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | N1926
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------