=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730502105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINA MADURO DPT, PT, WCC, CLT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2014
-----------------------------------------------------
Last Update Date | 01/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 NW 82ND AVE
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-442-1700
-----------------------------------------------------
Fax | 305-504-8897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6990 SW 110TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT5712
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------