Provider Demographics
NPI:1538106919
Name:CALIFORNIA CLUB MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:CALIFORNIA CLUB MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRNJA
Authorized Official - Suffix:IV
Authorized Official - Credentials:DO
Authorized Official - Phone:954-929-3400
Mailing Address - Street 1:850 IVES DAIRY ROAD
Mailing Address - Street 2:UNIT 14
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179
Mailing Address - Country:US
Mailing Address - Phone:305-405-0365
Mailing Address - Fax:305-405-0370
Practice Address - Street 1:850 IVES DAIRY ROAD
Practice Address - Street 2:UNIT 14
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179
Practice Address - Country:US
Practice Address - Phone:305-405-0365
Practice Address - Fax:305-405-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
FLHCC6244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6416Medicare PIN