1871192328 NPI number — WELLNESS COMMUNITY & MEDICAL CENTER INC

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 1871192328 NPI number — WELLNESS COMMUNITY & MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS COMMUNITY & MEDICAL CENTER INC
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:
1871192328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5030 SW 170TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHWEST RANCHES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33331-1217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-202-5536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
946 E 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33013-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-247-7067
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
MICHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-247-7067

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108571700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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