Provider Demographics
NPI:1235715236
Name:TAL COMMUNITY MENTAL HEALTH CENTER LLC
Entity Type:Organization
Organization Name:TAL COMMUNITY MENTAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-CFO
Authorized Official - Prefix:
Authorized Official - First Name:GASTON
Authorized Official - Middle Name:I
Authorized Official - Last Name:BOGOMOLNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-648-3588
Mailing Address - Street 1:12781 MIRAMAR PARKWAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027
Mailing Address - Country:US
Mailing Address - Phone:786-648-3588
Mailing Address - Fax:786-698-7677
Practice Address - Street 1:12781 MIRAMAR PARKWAY
Practice Address - Street 2:SUITE 203
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027
Practice Address - Country:US
Practice Address - Phone:786-648-3588
Practice Address - Fax:786-698-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-20
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109921400Medicaid