Basic Information
| Provider Information | |||||||||
| NPI: | 1760644397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JESSIE TRICE COMMUNITY HEALTH SYSTEM INC | ||||||||
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| OtherOrganizationName: | JESSIE TRICE COMMUNITY HEALTH CENTER INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5607 NW 27TH AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331422826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058051700 | ||||||||
| FaxNumber: | 3058051715 | ||||||||
| Practice Location | |||||||||
| Address1: | 15800 NW 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330546155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056376400 | ||||||||
| FaxNumber: | 3058051715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEASMAN | ||||||||
| AuthorizedOfficialFirstName: | ANNIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3058051700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 029542600 | 05 | FL | MEDICAID | 029542601 | 05 | FL | MEDICAID |