Provider Demographics
NPI: | 1942878624 |
---|---|
Name: | FENIX MEDICAL CENTER LLC |
Entity Type: | Organization |
Organization Name: | FENIX MEDICAL CENTER LLC |
Other - Org Name: | FENIX MEDICAL CENTER LLC |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | ONWER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | WALTER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GUITIERRE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | ETC |
Authorized Official - Phone: | 786-603-4356 |
Mailing Address - Street 1: | 7715 NW 48TH ST STE 360 |
Mailing Address - Street 2: | |
Mailing Address - City: | DORAL |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33166-5474 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 786-603-4356 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7715 NW 48TH ST STE 350 |
Practice Address - Street 2: | |
Practice Address - City: | DORAL |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33166-5473 |
Practice Address - Country: | US |
Practice Address - Phone: | 786-603-4356 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-06-17 |
Last Update Date: | 2021-08-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No | 251K00000X | Agencies | Public Health or Welfare |