=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902174683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULYTERAPIA SPA CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2011
-----------------------------------------------------
Last Update Date | 12/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9369 FOUNTAINBLEAU BLVD APT J108
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-970-2542
-----------------------------------------------------
Fax | 786-275-4132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9369 FOUNTAINBLEAU BLVD APT J108
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-970-2542
-----------------------------------------------------
Fax | 786-275-4132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JUDITH MOURINO
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 786-970-2542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number | MA-65381
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------