Provider Demographics
NPI:1982200382
Name:CLUB COMMUNITY CARE LLC
Entity Type:Organization
Organization Name:CLUB COMMUNITY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-497-1134
Mailing Address - Street 1:164 NW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3904
Mailing Address - Country:US
Mailing Address - Phone:786-587-9814
Mailing Address - Fax:
Practice Address - Street 1:164 NW MADISON ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3904
Practice Address - Country:US
Practice Address - Phone:786-587-9814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management