1720171895 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720171895 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720171895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8175 NW 12TH ST
Provider Second Line Business Mailing Address:
MICC BLDG SUITE 306 MIAMI DADE COUNTY HEALTH DEPARTMENT
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-1828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-845-0164
Provider Business Mailing Address Fax Number:
305-470-5846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8175 NW 12TH ST
Provider Second Line Business Practice Location Address:
MICC BLDG SUITE 306 MIAMI DADE COUNTY HEALTH DEPARTMENT
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33126-1828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-845-0164
Provider Business Practice Location Address Fax Number:
305-470-5846
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUSTAMANTE
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
REVENUE ADMINISTRATOR I
Authorized Official Telephone Number:
786-845-0164

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 027923400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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