=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770074627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE E QUINZADA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2018
-----------------------------------------------------
Last Update Date | 05/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18350 NW 2AVE
-----------------------------------------------------
City | MIAMI, GARDENS,FL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-756-9947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10740 SW 139TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-773-5977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT10810
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------