=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659627099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMON ADULT DAY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2012
-----------------------------------------------------
Last Update Date | 08/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2668 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-709-3298
-----------------------------------------------------
Fax | 786-709-3298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2668 SW 137TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-709-3298
-----------------------------------------------------
Fax | 786-709-3298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. OSVALDO RUIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-709-3298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | 9206
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------