=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770693491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITAS CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12300 SOUTHSHORE BLVD SUITE 105
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-798-2233
-----------------------------------------------------
Fax | 561-784-3903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1157 S STATE ROAD 7
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-798-2233
-----------------------------------------------------
Fax | 561-784-3903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JORGE DANIEL GHIRAGOSSIAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-798-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 6589
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------