Basic Information
| Provider Information | |||||||||
| NPI: | 1598248023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BORINQUEN HEALTH CARE CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BORINQUEN MEDICAL CENTERS - MAIN SITE DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055766611 | ||||||||
| FaxNumber: | 7864762818 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055766611 | ||||||||
| FaxNumber: | 7864762818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2018 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VELEZ | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055766611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BORINQUEN HEALTH CARE CENTER, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 023294200 | 05 | FL | MEDICAID | 023294201 | 05 | FL | MEDICAID |