=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710577481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOOL KIDZ SUCCESS CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2021
-----------------------------------------------------
Last Update Date | 01/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7900 NW 27TH AVE STE 237
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33147-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-544-7436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20535 NW 2ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-899-3617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. DONTAVIA WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-899-3617
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------