Basic Information
| Provider Information | |||||||||
| NPI: | 1619358751 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUIDEWELL SANITAS I, LLC | ||||||||
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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: | 7153 SW 117TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331832802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059217621 | ||||||||
| FaxNumber: | 3059217355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | FONSECA | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3059217621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.