MEDICARE: UNIVERSAL SA CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization		FL
2	305R00000X	Preferred Provider Organization		FL

General Provider Information

NPI Number	:	1700024015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSAL SA CORP.

Provider Business Mailing Address
First Line	:	2520 SW 22ND ST
Second Line	:	SUITE 2-070
City	:	CORAL GABLES
State	:	FL
Zip	:	33145-3438
Country	:	US
Telephone Number	:	305-513-5752
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 SW 22ND ST
Second Line	:	SUITE 2-070
City	:	CORAL GABLES
State	:	FL
Zip	:	33145-3438
Country	:	US
Telephone Number	:	305-513-5752
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEX PONTIGO
Credential	:
Telephone Number	:	305-513-5752

Provider Enumeration Date	:	01/23/2009
Last Update Date	:	01/23/2009

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Directions to “UNIVERSAL SA CORP. ” Practice Location

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