Provider Demographics
NPI:1801409891
Name:ADVANCED GROUP MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ADVANCED GROUP MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-355-1964
Mailing Address - Street 1:13401 SW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6117
Mailing Address - Country:US
Mailing Address - Phone:786-355-1964
Mailing Address - Fax:
Practice Address - Street 1:13401 SW 56TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6117
Practice Address - Country:US
Practice Address - Phone:786-355-1964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107956500Medicaid