Basic Information
| Provider Information | |||||||||
| NPI: | 1801320528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH STREET | ||||||||
| Address2: | CHEN MEDICAL CORPORATE OFFICE | ||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058314761 | ||||||||
| FaxNumber: | 3058314761 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 22ND AVENUE SOUTH | ||||||||
| Address2: | DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, LLC. | ||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058314761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2017 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ-CORTES | ||||||||
| AuthorizedOfficialFirstName: | GLADYS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3054984034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.