Provider Demographics
NPI:1407091069
Name:PROFESSIONAL HEALTH MANAGEMENT SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTH MANAGEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:GINNA
Authorized Official - Middle Name:VIVIANA
Authorized Official - Last Name:PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-547-2382
Mailing Address - Street 1:8260 W FLAGLER ST STE 2M
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2069
Mailing Address - Country:US
Mailing Address - Phone:305-559-4599
Mailing Address - Fax:305-553-0670
Practice Address - Street 1:8260 W FLAGLER ST STE 2M
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2069
Practice Address - Country:US
Practice Address - Phone:305-559-4599
Practice Address - Fax:305-553-0670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL562061-3302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization