Provider Demographics
NPI:1093987059
Name:DIVERSIFIED MENTAL HEALTH CARE CENTER INC
Entity Type:Organization
Organization Name:DIVERSIFIED MENTAL HEALTH CARE CENTER INC
Other - Org Name:DIVERSIFIED COMMUNITY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-256-9996
Mailing Address - Street 1:10961 SW 186TH ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6808
Mailing Address - Country:US
Mailing Address - Phone:305-256-9996
Mailing Address - Fax:
Practice Address - Street 1:10961 SW 186TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6808
Practice Address - Country:US
Practice Address - Phone:305-256-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8173208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty