=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962755462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMART MEDICAL DIAGNOSTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2012
-----------------------------------------------------
Last Update Date | 10/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2315 NW 107 STE 27
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-331-8180
-----------------------------------------------------
Fax | 305-704-8874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2315 NW 107TH AVE STE 27
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-331-8180
-----------------------------------------------------
Fax | 305-704-8874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. FELIPE D LERIDA JR.
-----------------------------------------------------
Credential | CPSGT
-----------------------------------------------------
Telephone | 786-797-4418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------