=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952012148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVIDA MEDICAL SERVICES L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2022
-----------------------------------------------------
Last Update Date | 02/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12030 SW 129TH CT STE 203
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-549-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12030 SW 129TH CT STE 203
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-549-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOSE MACIAS-RODRIGUEZ
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 954-549-5863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------