Provider Demographics
NPI:1801404769
Name:FMCG MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:FMCG MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTO
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:786-859-1073
Mailing Address - Street 1:3500 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6809
Mailing Address - Country:US
Mailing Address - Phone:786-859-1073
Mailing Address - Fax:305-555-0000
Practice Address - Street 1:3500 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6809
Practice Address - Country:US
Practice Address - Phone:786-859-1073
Practice Address - Fax:305-555-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center