Provider Demographics
NPI:1518191576
Name:ALFONSO PROFESSIONAL MEDICAL CTR
Entity Type:Organization
Organization Name:ALFONSO PROFESSIONAL MEDICAL CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:305-480-8473
Mailing Address - Street 1:11180 W FLAGLER ST
Mailing Address - Street 2:STE 13
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1216
Mailing Address - Country:US
Mailing Address - Phone:305-480-8473
Mailing Address - Fax:305-480-8472
Practice Address - Street 1:11180 W FLAGLER STREET
Practice Address - Street 2:STE 13
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1215
Practice Address - Country:US
Practice Address - Phone:305-480-8473
Practice Address - Fax:305-480-8472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 42956261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 42956OtherSTATE OF FLORIDA DEPT OF HEALTH