=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851693063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOURCE OF LIFE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2010
-----------------------------------------------------
Last Update Date | 11/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 SW 77TH CT APT 301
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-344-1998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4011 W FLAGLER ST STE 301
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-644-2800
-----------------------------------------------------
Fax | 305-644-2101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PEDRO SANCHEZ
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 786-344-3001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | MA59149
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------