=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912510751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABC HEALTH CARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2020
-----------------------------------------------------
Last Update Date | 08/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9766 SW 24TH ST STE 17AND
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-7539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-706-1281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9766 SW 24TH ST STE 17AND
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-7539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-706-1281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MBR
-----------------------------------------------------
Name | GREETTEL O PORTAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-748-3462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------