Basic Information
| Provider Information | |||||||||
| NPI: | 1134894462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH DADE PRIMARY CARE, LLC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14750 NW 77TH CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330161507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7867583152 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4450 E FLETCHER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136328861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALENZUELA | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
| AuthorizedOfficialMiddleName: | LUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3057253705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH DADE PRIMARY CARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.