Provider Demographics
NPI:1952074650
Name:BANYAN COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:BANYAN COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRODEGUAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-398-6100
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2080
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:
Practice Address - Street 1:3850 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1604
Practice Address - Country:US
Practice Address - Phone:305-774-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-28
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111575800Medicaid