Provider Demographics
NPI:1972603942
Name:COMMUNITY MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-694-9364
Mailing Address - Street 1:531 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3812
Mailing Address - Country:US
Mailing Address - Phone:305-694-9364
Mailing Address - Fax:305-694-9375
Practice Address - Street 1:531 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3812
Practice Address - Country:US
Practice Address - Phone:305-694-9364
Practice Address - Fax:305-694-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC7234OtherAHCA LICENSE