=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801037536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIRVANA HOLISTIC HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2009
-----------------------------------------------------
Last Update Date | 03/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 BARWICK ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-668-9331
-----------------------------------------------------
Fax | 407-517-0339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 BARWICK ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-668-9331
-----------------------------------------------------
Fax | 407-517-0339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. ADOLFO TRINIDAD ORTIZ
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 407-668-9331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------