Basic Information
| Provider Information | |||||||||
| NPI: | 1366085821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CARE RESOURCES OF FL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15800 PINES BLVD STE 332 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330271212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543625432 | ||||||||
| FaxNumber: | 8662404606 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 DOUGLAS AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327142555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074017457 | ||||||||
| FaxNumber: | 4075980885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 02/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | URTEAGA | ||||||||
| AuthorizedOfficialFirstName: | FANCISCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4074017457 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 172V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | GRANT | 01 | FL | STATE OF FLORIDA | OTHER |