Provider Demographics
NPI:1275030116
Name:SANDIEGO MEDICAL SERVICE INC.
Entity Type:Organization
Organization Name:SANDIEGO MEDICAL SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUZ MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RACEDEO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:305-467-4442
Mailing Address - Street 1:11925 BIRD DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3571
Mailing Address - Country:US
Mailing Address - Phone:305-467-4442
Mailing Address - Fax:
Practice Address - Street 1:11925 BIRD DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3571
Practice Address - Country:US
Practice Address - Phone:305-467-4442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-08
Last Update Date:2018-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9244232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty