=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740873876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNIFICO MEDICAL CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2021
-----------------------------------------------------
Last Update Date | 02/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4531 DELEON ST STE 201
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-208-2146
-----------------------------------------------------
Fax | 239-672-8620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4531 DELEON ST STE 201
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-208-2146
-----------------------------------------------------
Fax | 239-672-8620
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARILYN IGLESIAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-208-2146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------