=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912459272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDOCRINE HEALTH AND WELLNESS OF SOUTH FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2016
-----------------------------------------------------
Last Update Date | 05/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12060 SW 129TH CT STE 205
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-592-2744
-----------------------------------------------------
Fax | 949-404-6517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14720 JACKSON ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-7450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-951-2152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA MARIA COLLIER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 305-951-2152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | OS11351
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------