Provider Demographics
NPI:1689059453
Name:LA CLINIQUE 300 INC
Entity Type:Organization
Organization Name:LA CLINIQUE 300 INC
Other - Org Name:JOSEPH FANFAN JR MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FANFAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-525-4900
Mailing Address - Street 1:2630 N ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2550
Mailing Address - Country:US
Mailing Address - Phone:954-525-4900
Mailing Address - Fax:954-396-3110
Practice Address - Street 1:2630 N ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-2550
Practice Address - Country:US
Practice Address - Phone:954-525-4900
Practice Address - Fax:954-396-3110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOSEPH FANFAN JR MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-22
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43065261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068166100Medicaid
FL94236Medicare PIN
FL068166100Medicaid