=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942479795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICAL AND WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10111 FOREST HILL BLVD SUITE 230
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-721-1953
-----------------------------------------------------
Fax | 561-721-2257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10111 FOREST HILL BLVD SUITE 230
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-721-1953
-----------------------------------------------------
Fax | 561-721-2257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VANESSA VIZCAINO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-721-1953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME 87499
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------