Provider Demographics
NPI:1780827055
Name:JUVENICE PROFESSIONAL CENTER CORP
Entity Type:Organization
Organization Name:JUVENICE PROFESSIONAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEDIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-910-9170
Mailing Address - Street 1:8567 CORAL WAY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-2335
Mailing Address - Country:US
Mailing Address - Phone:305-910-9170
Mailing Address - Fax:305-513-5189
Practice Address - Street 1:8567 CORAL WAY
Practice Address - Street 2:SUITE 112
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2335
Practice Address - Country:US
Practice Address - Phone:305-910-9170
Practice Address - Fax:305-513-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT199632081S0010X
FLME61828305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty