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General NPI Number Information
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NPI Number | 1780827055
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Entity Type | Organization
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Legal Business Name | JUVENICE PROFESSIONAL CENTER CORP
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Dates
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Enumeration Date | 04/15/2009
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Last Update Date | 05/25/2009
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Provider Practice Location Address
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Address Line | 8567 CORAL WAY SUITE 112
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City | MIAMI
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State | FL
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Zip | 33155-2335
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Country | US
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Telephone | 305-910-9170
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Fax | 305-513-5189
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Provider Business Mailing Address
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Address Line | 8567 CORAL WAY SUITE 112
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City | MIAMI
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State | FL
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Zip | 33155-2335
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Country | US
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Telephone | 305-910-9170
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Fax | 305-513-5189
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Authorized Official
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Title or Position | PRESIDENT
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Name | LUIS CHEDIAK
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Credential |
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Telephone | 305-910-9170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | PT19963
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | ME61828
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License Number State | FL
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