Provider Demographics
NPI:1659446839
Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Other - Org Name:JACKSON NORTH COMMUNITY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ENEIDA
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROLDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-585-6754
Mailing Address - Street 1:15055 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3365
Mailing Address - Country:US
Mailing Address - Phone:786-466-2701
Mailing Address - Fax:
Practice Address - Street 1:15055 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3365
Practice Address - Country:US
Practice Address - Phone:786-466-2701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL194393336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBJ8447345Medicare UPIN
FL19439Medicare UPIN