=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821469362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORTIES STAFFING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2015
-----------------------------------------------------
Last Update Date | 05/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15390 SW 144TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-357-0013
-----------------------------------------------------
Fax | 305-859-4253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15390 SW 144TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-1061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-357-0013
-----------------------------------------------------
Fax | 305-859-4253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MAJELA HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-357-0013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | 234112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 234112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 234112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------