Provider Demographics
NPI:1144235094
Name:EXTRA MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:EXTRA MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:V
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-441-5722
Mailing Address - Street 1:717 PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2060
Mailing Address - Country:US
Mailing Address - Phone:305-441-5722
Mailing Address - Fax:
Practice Address - Street 1:717 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2060
Practice Address - Country:US
Practice Address - Phone:305-441-5722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4063208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID#
FL=========OtherTAX ID#