Provider Demographics
NPI:1134116320
Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Other - Org Name:JACKSON MEMORIAL LONG TERM CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-585-3701
Mailing Address - Street 1:2500 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-8429
Mailing Address - Country:US
Mailing Address - Phone:786-466-3000
Mailing Address - Fax:305-638-6856
Practice Address - Street 1:2500 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-8429
Practice Address - Country:US
Practice Address - Phone:786-466-3000
Practice Address - Fax:305-638-6856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1243096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020416100Medicaid
FL3767620002Medicare NSC
FL105392Medicare Oscar/Certification