Basic Information
| Provider Information | |||||||||
| NPI: | 1396124046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUIDEWELL SANITAS I, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINISANITAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 8400 NW 33RD ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331221937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059217621 | ||||||||
| FaxNumber: | 3059217355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | FONSECA | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3059217621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| 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.