Provider Demographics
NPI:1891117362
Name:MEDPLAN CLINIC, LLC
Entity Type:Organization
Organization Name:MEDPLAN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IGLESIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-641-5348
Mailing Address - Street 1:8750 NW 36TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178
Mailing Address - Country:US
Mailing Address - Phone:786-641-5348
Mailing Address - Fax:305-615-1121
Practice Address - Street 1:4218 E 4 AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013
Practice Address - Country:US
Practice Address - Phone:305-262-1610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018781000Medicaid