Basic Information
| Provider Information | |||||||||
| NPI: | 1346757432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEDICATED SENIOR MEDICAL CENTER OF FLORIDA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEDICATED SENIOR MEDICAL CENTER ARLINGTON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH STREET | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9422 ARLINGTON EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3056286117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEDICATED SENIOR MEDICAL CENTER OF FLORIDA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.