Provider Demographics
NPI:1356936124
Name:LAS OLAS COMMUNITY HEALTH CORP
Entity type:Organization
Organization Name:LAS OLAS COMMUNITY HEALTH CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILKA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANCIO-ALONSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-614-6736
Mailing Address - Street 1:4005 NW 114TH AVE UNIT 22
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4373
Mailing Address - Country:US
Mailing Address - Phone:786-614-6736
Mailing Address - Fax:
Practice Address - Street 1:4005 NW 114TH AVE UNIT 22
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4373
Practice Address - Country:US
Practice Address - Phone:786-614-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2021009669OtherLICENSE