Basic Information
| Provider Information | |||||||||
| NPI: | 1538106919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA CLUB MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 IVES DAIRY ROAD | ||||||||
| Address2: | UNIT 14 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054050365 | ||||||||
| FaxNumber: | 3054050370 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 IVES DAIRY ROAD | ||||||||
| Address2: | UNIT 14 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054050365 | ||||||||
| FaxNumber: | 3054050370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRNJA | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9549293400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | HCC6244 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.