Provider Demographics
NPI:1639641392
Name:CORAL BLUE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:CORAL BLUE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:IZQUIERDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-641-5100
Mailing Address - Street 1:8890 SW 24TH ST STE 214
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2060
Mailing Address - Country:US
Mailing Address - Phone:786-641-5100
Mailing Address - Fax:786-456-5350
Practice Address - Street 1:8890 SW 24TH ST STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2060
Practice Address - Country:US
Practice Address - Phone:786-641-5100
Practice Address - Fax:786-456-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center