Provider Demographics
NPI:1619428877
Name:PROF/GUIDEWELL SANITAS MED CNT
Entity Type:Organization
Organization Name:PROF/GUIDEWELL SANITAS MED CNT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:HERNAN
Authorized Official - Last Name:VELARDE-LASSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-353-5770
Mailing Address - Street 1:11211 VERANDA CT
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7101
Mailing Address - Country:US
Mailing Address - Phone:516-353-5770
Mailing Address - Fax:
Practice Address - Street 1:11211 VERANDA CT
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7101
Practice Address - Country:US
Practice Address - Phone:516-353-5770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME125796261Q00000X, 261QA0600X
NY226893261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02488824Medicaid
NYH83144Medicaid