Provider Demographics
NPI:1487657516
Name:HELEN B BENTLEY FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:HELEN B BENTLEY FAMILY HEALTH CENTER
Other - Org Name:COCONUT GROVE FAMILY HEALTH CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-351-1314
Mailing Address - Street 1:3090 SW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4311
Mailing Address - Country:US
Mailing Address - Phone:305-447-4950
Mailing Address - Fax:305-444-7866
Practice Address - Street 1:3090 SW 37TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4311
Practice Address - Country:US
Practice Address - Phone:305-447-4950
Practice Address - Fax:305-444-7866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL719670261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0295553100Medicaid
FL0295553100Medicaid