=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659648848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE & HOPE MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2011
-----------------------------------------------------
Last Update Date | 11/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28321 S TAMIAMI TRL # A3
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-3226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-821-0713
-----------------------------------------------------
Fax | 305-220-5015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28321 S TAMIAMI TRL # A3
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-3226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-821-0713
-----------------------------------------------------
Fax | 305-220-5015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | BARBARA GONZALEZ I
-----------------------------------------------------
Credential | MASSAGE THERAPIST
-----------------------------------------------------
Telephone | 239-821-0713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | MA60379
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------