Provider Demographics
NPI:1740801877
Name:MOLINA PROVIDER CARE
Entity Type:Organization
Organization Name:MOLINA PROVIDER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARANGELY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-334-1166
Mailing Address - Street 1:2544 ISABELA TER
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-5816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2544 ISABELA TER
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-5816
Practice Address - Country:US
Practice Address - Phone:407-334-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18003090Medicaid