=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831437722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARITZA GOMEZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2013
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13370 SW 82ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-587-9060
-----------------------------------------------------
Fax | 786-362-6304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13370 SW 82ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-587-9060
-----------------------------------------------------
Fax | 786-362-6304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARITZA GOMEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-587-9060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 6906456
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------