=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760673503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2007
-----------------------------------------------------
Last Update Date | 08/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13730 NW 6TH CT
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33168-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-891-3439
-----------------------------------------------------
Fax | 305-892-6612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13730 NW 6TH CT
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33168-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-891-3439
-----------------------------------------------------
Fax | 305-892-6612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | EDWARD MORROW
-----------------------------------------------------
Credential | MBA, CPA
-----------------------------------------------------
Telephone | 727-656-9272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | PH 22068
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------