Provider Demographics
NPI:1902195191
Name:INSTITUTE OF PREVENTIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:INSTITUTE OF PREVENTIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OTNIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:305-676-2300
Mailing Address - Street 1:1275 W 47TH PL
Mailing Address - Street 2:SUITE 422
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3394
Mailing Address - Country:US
Mailing Address - Phone:305-676-2300
Mailing Address - Fax:888-601-0076
Practice Address - Street 1:1275 W 47TH PL
Practice Address - Street 2:SUITE 422
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3394
Practice Address - Country:US
Practice Address - Phone:305-676-2300
Practice Address - Fax:888-601-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3081082261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308614300Medicaid
FLAJ034YMedicare PIN