Provider Demographics
NPI:1467937623
Name:MEMORIAL HEALTHCARE SYSTEM AMBULATORY CARE CENTER, LLC
Entity Type:Organization
Organization Name:MEMORIAL HEALTHCARE SYSTEM AMBULATORY CARE CENTER, LLC
Other - Org Name:SOUTH BROWARD HOSPITAL DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCHESNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-265-3451
Mailing Address - Street 1:3111 STIRLING RD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6566
Mailing Address - Country:US
Mailing Address - Phone:954-265-3451
Mailing Address - Fax:
Practice Address - Street 1:3377 SOUTH STATE ROAD 7 SUITE 200
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8082
Practice Address - Country:US
Practice Address - Phone:954-265-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical