Provider Demographics
NPI:1689605362
Name:JESSIE TRICE COMMUNITY HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:JESSIE TRICE COMMUNITY HEALTH SYSTEM, INC
Other - Org Name:JESSIE TRICE COMMUNITY HEALTH CENTER INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEASMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-805-1700
Mailing Address - Street 1:5607 NW 27TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2826
Mailing Address - Country:US
Mailing Address - Phone:305-805-1700
Mailing Address - Fax:305-805-1715
Practice Address - Street 1:5361 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-8035
Practice Address - Country:US
Practice Address - Phone:305-637-6400
Practice Address - Fax:305-805-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QC1500X
FL5143177261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029541800Medicaid
FL060826200Medicaid
FL029541801Medicaid
FL029541800Medicaid
FL053833700Medicaid