Provider Demographics
NPI:1407271844
Name:MIAMI MEDICAL & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MIAMI MEDICAL & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:DUMENIGO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:305-534-0076
Mailing Address - Street 1:1200 ALTON RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-3810
Mailing Address - Country:US
Mailing Address - Phone:305-534-0076
Mailing Address - Fax:305-532-5868
Practice Address - Street 1:551 E 49TH ST
Practice Address - Street 2:SUITE 1-8
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1904
Practice Address - Country:US
Practice Address - Phone:305-532-3923
Practice Address - Fax:305-532-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLID353AOtherMEDICARE PTAN
FL11761QOtherMEDICARE PTAN DUM
FLE6931SOtherMEDICARE PTAN ALO
FLGK944YOtherPTAN DE L
FLH83310Medicare UPIN