=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821425505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIALIZED SPEECH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2013
-----------------------------------------------------
Last Update Date | 09/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3335 N UNIVERSITY DR SUITE 5
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-442-9422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3335 N UNIVERSITY DR SUITE 5
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | JOHN TOMBASCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-442-9422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SZ6409
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------