1356068621 NPI number — UNIVIDA MEDICAL CENTER LLC

Table of content: (NPI 1356068621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356068621 NPI number — UNIVIDA MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVIDA MEDICAL CENTER LLC
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:
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:
1356068621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 NW 42ND AVE
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-3667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-204-0333
Provider Business Mailing Address Fax Number:
305-359-7546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 NW 79TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33166-6508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-204-0333
Provider Business Practice Location Address Fax Number:
305-359-7546
Provider Enumeration Date:
10/26/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
ORLANDO
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
305-504-7885

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114295506 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114295508 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".