Provider Demographics
NPI:1790231728
Name:SAN LAZARO MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SAN LAZARO MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NIDIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-294-0442
Mailing Address - Street 1:3271 NW 7TH ST STE 211
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-4141
Mailing Address - Country:US
Mailing Address - Phone:786-294-0442
Mailing Address - Fax:786-294-0124
Practice Address - Street 1:3271 NW 7TH ST STE 211
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4141
Practice Address - Country:US
Practice Address - Phone:786-294-0442
Practice Address - Fax:786-294-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty