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General NPI Number Information
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NPI Number | 1780628107
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Entity Type | Organization
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Legal Business Name | EVANESCENCE INC
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Dates
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Enumeration Date | 06/15/2006
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Last Update Date | 07/10/2007
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Provider Practice Location Address
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Address Line | 11760 BIRD ROAD SUITE 710
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City | KENDALL
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State | FL
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Zip | 33165
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Country | US
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Telephone | 305-598-8222
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Fax | 305-554-0616
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Provider Business Mailing Address
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Address Line | 7100 PINES BLVD SUITE 23
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City | PEMBROKE PINES
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State | FL
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Zip | 33024-7355
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Country | US
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Telephone | 954-967-0107
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Fax | 954-967-0109
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | GUSTAVO G LEON
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Credential | M.D.
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Telephone | 305-598-8222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | ME 29633
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License Number State | FL
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