Basic Information
Provider Information | |||||||||
NPI: | 1215328224 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GUIDEWELL SANITAS I, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLINISANTIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8400 NW 33RD ST | ||||||||
Address2: | SUITE: 100 | ||||||||
City: | DORAL | ||||||||
State: | FL | ||||||||
PostalCode: | 331221937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3059217621 | ||||||||
FaxNumber: | 3059217355 | ||||||||
Practice Location | |||||||||
Address1: | 18610 NW 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | HIALEAH | ||||||||
State: | FL | ||||||||
PostalCode: | 330153518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3059217621 | ||||||||
FaxNumber: | 3059217355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2015 | ||||||||
LastUpdateDate: | 08/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FONSECA | ||||||||
AuthorizedOfficialFirstName: | FERNANDO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3059217621 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GUIDEWELL SANITAS I, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.