Basic Information
| Provider Information | |||||||||
| NPI: | 1063694446 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINIQUE MEDMANAGEMENT GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LA CLINIQUE SOLEIL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 750 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330205424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543428800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330205424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543428800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BACCHELLI | ||||||||
| AuthorizedOfficialFirstName: | SANDRO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | M.D./OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9543428800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34696 | 01 | FL | BCBS | OTHER |