Basic Information
| Provider Information | |||||||||
| NPI: | 1427677319 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PASSQUAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PASSQUAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18300 NW 62ND AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330158207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866779922 | ||||||||
| FaxNumber: | 8448953066 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 NW 62ND AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330158207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866779922 | ||||||||
| FaxNumber: | 8448953066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2020 | ||||||||
| LastUpdateDate: | 04/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEREZ PASCUAL | ||||||||
| AuthorizedOfficialFirstName: | HENDRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3058985440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 898036 | 05 | CA | MEDICAID |