Provider Demographics
NPI:1376803908
Name:OPEN TIME SUPPORT
Entity Type:Organization
Organization Name:OPEN TIME SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:PAULINO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCABA
Authorized Official - Phone:786-317-2004
Mailing Address - Street 1:15075 SW 63RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2784
Mailing Address - Country:US
Mailing Address - Phone:786-317-2004
Mailing Address - Fax:305-388-1570
Practice Address - Street 1:15075 SW 63RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2784
Practice Address - Country:US
Practice Address - Phone:786-317-2004
Practice Address - Fax:305-388-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health