=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841748415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JNISSI SIGNATURE COLLECTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2016
-----------------------------------------------------
Last Update Date | 09/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 NE 171ST TER
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33162-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-617-2606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 NE 171ST TER
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33162-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-617-2606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRANIAL PROSTHESIS SPECILAIST
-----------------------------------------------------
Name | VENECIA LASALLE JEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-617-2606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------