=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700808805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE MATERNITY AND WOMENS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 EAST SAMPLE ROAD SUITE 201
-----------------------------------------------------
City | LIGHTHOUSE POINT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-781-0180
-----------------------------------------------------
Fax | 954-781-3230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 EAST SAMPLE ROAD SUITE 201
-----------------------------------------------------
City | LIGHTHOUSE POINT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-781-0180
-----------------------------------------------------
Fax | 954-781-3230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | ANTHONY A CHIDIAC
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-781-0180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | ME43336
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------