Basic Information
| Provider Information | |||||||||
| NPI: | 1942822242 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH OF SOUTH FLORIDA INC | ||||||||
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| OtherOrganizationName: | CHI MOBILE MEDICAL VAN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10300 SW 216TH ST | ||||||||
| Address2: | |||||||||
| City: | CUTLER BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331901003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052535100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10300 SW 216TH ST | ||||||||
| Address2: | |||||||||
| City: | CUTLER BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331901003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052535100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2020 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARTLEY | ||||||||
| AuthorizedOfficialFirstName: | BRODES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3052535100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 029572800 | 05 | FL | MEDICAID | 1336152347 | 01 | FL | NPI | OTHER |