=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992129001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRP PHYSICIAN SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2014
-----------------------------------------------------
Last Update Date | 02/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 NW 7TH ST B111
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-426-9716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 NW 7TH ST B111
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-426-9716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. NILO M SIERRA
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 786-426-9716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------