Basic Information
| Provider Information | |||||||||
| NPI: | 1720215106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOTAL MEDICAL LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12177 PEMBROKE ROAD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544360555 | ||||||||
| FaxNumber: | 9544360108 | ||||||||
| Practice Location | |||||||||
| Address1: | 12177 PEMBROKE ROAD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544360555 | ||||||||
| FaxNumber: | 9544360108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | WINSTON | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9544360555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | HCC3975 | 01 | FL | AHCA LICENSE | OTHER | HCC3975 | 01 | FL | AHCA | OTHER |