=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891223145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORAL THERAPY GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 W FLAGLER ST STE 215
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33135-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-586-2088
-----------------------------------------------------
Fax | 786-953-5613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 W FLAGLER ST STE 215
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33135-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-586-2088
-----------------------------------------------------
Fax | 786-953-5613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GISELLE IBANEZ
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 305-586-2088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------