MEDICARE: MIAMI LAKES THERAPY CENTER, INC

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	261QH0700X	Hearing and Speech Clinic/Center
2	225X00000X	Occupational Therapist
3	225100000X	Physical Therapist
4	225800000X	Recreation Therapist
5	235Z00000X	Speech-Language Pathologist	SA9388	FL

General Provider Information

NPI Number	:	1700101912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI LAKES THERAPY CENTER, INC

Provider Business Mailing Address
First Line	:	6073 NW 167TH ST
Second Line	:	C13
City	:	HIALEAH
State	:	FL
Zip	:	33015-4336
Country	:	US
Telephone Number	:	305-362-5328
Fax Number	:	305-362-3303

Provider Business Practice Location Address
First Line	:	6073 NW 167TH ST
Second Line	:	C13
City	:	HIALEAH
State	:	FL
Zip	:	33015-4336
Country	:	US
Telephone Number	:	305-362-5328
Fax Number	:	305-362-3303

Authorized Official
Title or Position	:	OWNER
Name	:	MS. PATRICIA PELAEZ
Credential	:	ADMINISTRATOR
Telephone Number	:	305-790-0223

Provider Enumeration Date	:	03/30/2010
Last Update Date	:	04/01/2010

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