=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902142763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI LAKES REHAB SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2012
-----------------------------------------------------
Last Update Date | 12/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13903 NW 67TH AVE SUITE # 250
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-439-3996
-----------------------------------------------------
Fax | 786-439-3997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13903 NW 67TH AVE SUITE # 250
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-439-3996
-----------------------------------------------------
Fax | 786-439-3997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSE ZULUETA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-439-3996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | HCC8269
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------