Basic Information
Provider Information | |||||||||
NPI: | 1700393881 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEDICATED SENIOR MEDICAL CENTER OF FLORIDA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DEDICATED SENIOR MEDICAL CENTER NORTH TAMPA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1395 NW 167TH STREET | ||||||||
Address2: |   | ||||||||
City: | MIAMI GARDENS | ||||||||
State: | FL | ||||||||
PostalCode: | 33169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056286117 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1901 FLETCHER AVENUE | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 33612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056286117 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2018 | ||||||||
LastUpdateDate: | 01/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JIMENEZ | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3056286117 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DEDICATED SENIOR MEDICAL CENTER OF FLORIDA | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | N |   | Suppliers | Non-Pharmacy Dispensing Site |   | 174400000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.