Provider Demographics
NPI:1396033080
Name:125ST NM CORP
Entity Type:Organization
Organization Name:125ST NM CORP
Other - Org Name:125TH STREET MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-235-7240
Mailing Address - Street 1:505 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4718
Mailing Address - Country:US
Mailing Address - Phone:786-235-7240
Mailing Address - Fax:786-235-7241
Practice Address - Street 1:505 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-4718
Practice Address - Country:US
Practice Address - Phone:786-235-7240
Practice Address - Fax:786-235-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty