Provider Demographics
NPI:1124203096
Name:ACQUALINA MEDICAL GROUP AND THERAPEUTIC SERVICES INC
Entity Type:Organization
Organization Name:ACQUALINA MEDICAL GROUP AND THERAPEUTIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FLAVIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-269-8812
Mailing Address - Street 1:8150 SW 8TH ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4263
Mailing Address - Country:US
Mailing Address - Phone:305-269-8812
Mailing Address - Fax:305-269-8814
Practice Address - Street 1:8150 SW 8TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4263
Practice Address - Country:US
Practice Address - Phone:305-269-8812
Practice Address - Fax:305-269-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC6486OtherAHCA LICENSE
FLAK030Medicare PIN