Basic Information
| Provider Information | |||||||||
| NPI: | 1770974784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUIDEWELL SANITAS I, LLC | ||||||||
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| OtherOrganizationName: | CLINISANITAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2000 NW 87TH AVENUE | ||||||||
| Address2: | SUITES 101 AND 102 | ||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331722409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059217621 | ||||||||
| FaxNumber: | 3059217355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2015 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | FONSECA | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3059217621 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GUIDEWELL SANITAS I, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.