Provider Demographics
NPI:1710360482
Name:BANYAN COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:BANYAN COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRODEGUAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-398-6100
Mailing Address - Street 1:6100 BLUE LAGOON DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2079
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:
Practice Address - Street 1:220 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-4611
Practice Address - Country:US
Practice Address - Phone:954-941-9828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012558510Medicaid