Provider Demographics
NPI:1396180535
Name:MY CLINIC INTEGRAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MY CLINIC INTEGRAL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YUSDEIVYS
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA62083
Authorized Official - Phone:786-378-0649
Mailing Address - Street 1:2711 SW 137TH AVE
Mailing Address - Street 2:#93
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6359
Mailing Address - Country:US
Mailing Address - Phone:305-646-1932
Mailing Address - Fax:305-967-8106
Practice Address - Street 1:2711 SW 137TH AVE
Practice Address - Street 2:#93
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6359
Practice Address - Country:US
Practice Address - Phone:305-646-1932
Practice Address - Fax:305-967-8106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62083305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service