Provider Demographics
NPI:1447618442
Name:PROFESSIONAL MEDICAL PRACTICE
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:YANET
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-821-1613
Mailing Address - Street 1:7221 SW 24 STREET
Mailing Address - Street 2:SUITE #202A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155
Mailing Address - Country:US
Mailing Address - Phone:786-294-0811
Mailing Address - Fax:786-362-5244
Practice Address - Street 1:11246 SW 137TH AVE STE 202A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4201
Practice Address - Country:US
Practice Address - Phone:786-631-5999
Practice Address - Fax:786-362-5244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10584208D00000X, 225100000X
261Q00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261QA0600XMedicaid