Provider Demographics
NPI:1073667465
Name:MIAMI LAKES MEDICAL,INC
Entity Type:Organization
Organization Name:MIAMI LAKES MEDICAL,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:305-558-8838
Mailing Address - Street 1:6175 NW 167TH ST
Mailing Address - Street 2:SUITE G-25
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4339
Mailing Address - Country:US
Mailing Address - Phone:305-558-8838
Mailing Address - Fax:305-558-8011
Practice Address - Street 1:6175 NW 167TH ST
Practice Address - Street 2:SUITE G-25
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4339
Practice Address - Country:US
Practice Address - Phone:305-558-8838
Practice Address - Fax:305-558-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL319332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL951286100Medicaid
FL0994770001Medicare NSC