Provider Demographics
NPI:1609199017
Name:SACRED HEART MEDICAL OFFICE PA
Entity Type:Organization
Organization Name:SACRED HEART MEDICAL OFFICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YVELICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILLAMAN-BENCOSME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-392-0333
Mailing Address - Street 1:17901 NW 5TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2810
Mailing Address - Country:US
Mailing Address - Phone:954-392-0333
Mailing Address - Fax:954-392-0393
Practice Address - Street 1:17901 NW 5TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2810
Practice Address - Country:US
Practice Address - Phone:954-392-0333
Practice Address - Fax:954-392-0393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64482261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001454700Medicaid