Provider Demographics
NPI:1376011551
Name:PERSONALIZED MEDICINE INSTITUTE, LLC.
Entity Type:Organization
Organization Name:PERSONALIZED MEDICINE INSTITUTE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVEL
Authorized Official - Middle Name:CRISTINA
Authorized Official - Last Name:DE FREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-300-0147
Mailing Address - Street 1:6030 REESE RD APT 404
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1243
Mailing Address - Country:US
Mailing Address - Phone:203-300-0147
Mailing Address - Fax:954-634-4293
Practice Address - Street 1:4765 SW 148TH AVE STE 404
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2128
Practice Address - Country:US
Practice Address - Phone:203-300-0147
Practice Address - Fax:954-634-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME107216OtherINTERNAL MEDICINE