=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932656253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARROUSEL MEDICAL CENTER CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2016
-----------------------------------------------------
Last Update Date | 09/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 BUDINGER AVE
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34769-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-414-8409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3201 BUDINGER AVE
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34769-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-414-8409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. REYNALDO PEZZOTTI
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 939-969-2068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------