Basic Information
| Provider Information | |||||||||
| NPI: | 1568842615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JESSIE TRICE COMMUNITY HEALTH SYSTEM INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JESSIE TRICE COMMUNITY HEALTH CENTER INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5607 NW 27TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331422826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058051700 | ||||||||
| FaxNumber: | 3058051715 | ||||||||
| Practice Location | |||||||||
| Address1: | 5607 NW 27TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331422826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058051700 | ||||||||
| FaxNumber: | 3058051715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEASMAN | ||||||||
| AuthorizedOfficialFirstName: | ANNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3058051700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN12903 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 072897700 | 05 | FL | MEDICAID |