Provider Demographics
NPI:1861655656
Name:JESSIE TRICE COMMUNITY HEALTH SYSTEM INC
Entity Type:Organization
Organization Name:JESSIE TRICE COMMUNITY HEALTH SYSTEM INC
Other - Org Name:JESSIE TRICE COMMUNITY HEALTH CENTER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEASMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-805-1700
Mailing Address - Street 1:5607 NW 27TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2826
Mailing Address - Country:US
Mailing Address - Phone:305-805-1700
Mailing Address - Fax:305-805-1715
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-637-6400
Practice Address - Fax:305-805-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029541804Medicaid
FL029541805Medicaid
FL101964Medicare Oscar/Certification