Basic Information
| Provider Information | |||||||||
| NPI: | 1285748285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH DADE PRIMARY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14750 NW 77TH CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330161507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864851005 | ||||||||
| FaxNumber: | 7864412156 | ||||||||
| Practice Location | |||||||||
| Address1: | 9835 E HIBISCUS ST | ||||||||
| Address2: | |||||||||
| City: | PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331575406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052388561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | PALENZUELA | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3057253705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLAREMEDICA HEALTH PARTNERS, LLC | ||||||||
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| AuthorizedOfficialCredential: | AUTHORIZED OFFICIAL | ||||||||
| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0027176 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME0092409 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME0016658 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01-02953 | 01 | UNITED HEALTHCARE | OTHER | 15296 | 01 | AETNA INSURANCE | OTHER | 15313 | 01 | AETNA INSURANCE | OTHER | 79328 | 01 | BLEU CROSS BLUE SHIELD FL | OTHER | 71520 | 01 | BLUE CROSS BLUE SHIELD FL | OTHER | 4347956 | 01 | AETNA INSURANCE | OTHER | 005597 | 01 | NEIGHBORHOOD HEALTH PARTN | OTHER | 01-02956 | 01 | UNITED HEALTHCARE | OTHER | 4497709 | 01 | AETNA INSURANCE | OTHER |