Provider Demographics
NPI:1679844336
Name:ST JUDE PROFESSIONAL SERVICE INC
Entity Type:Organization
Organization Name:ST JUDE PROFESSIONAL SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PINEIRO
Authorized Official - Suffix:SR
Authorized Official - Credentials:LMT
Authorized Official - Phone:786-360-1452
Mailing Address - Street 1:2387 W 68TH ST
Mailing Address - Street 2:504
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6889
Mailing Address - Country:US
Mailing Address - Phone:786-360-1452
Mailing Address - Fax:786-360-1877
Practice Address - Street 1:2387 W 68TH ST
Practice Address - Street 2:504
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6889
Practice Address - Country:US
Practice Address - Phone:786-360-1452
Practice Address - Fax:786-360-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10256261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center