Provider Demographics
NPI:1568890523
Name:PRIME SOUTH FLORIDA P.A INC.
Entity Type:Organization
Organization Name:PRIME SOUTH FLORIDA P.A INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISMELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUJILLO GAMA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:305-378-9968
Mailing Address - Street 1:11285 SW 211TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2211
Mailing Address - Country:US
Mailing Address - Phone:305-378-9968
Mailing Address - Fax:
Practice Address - Street 1:11285 SW 211TH ST STE 205
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2211
Practice Address - Country:US
Practice Address - Phone:305-378-9968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100183261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service