=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902515810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSE ORCASITA-NG, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 W 12TH AVE UNIT 21-22
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-5154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-362-9560
-----------------------------------------------------
Fax | 305-827-1581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 NW 57TH CT STE 400
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-649-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | JOSEPH N DE VERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-649-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------