Provider Demographics
NPI:1457760712
Name:PROVIDENCE COMMUNITY CENTER LLC
Entity Type:Organization
Organization Name:PROVIDENCE COMMUNITY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULINA
Authorized Official - Middle Name:T
Authorized Official - Last Name:DORVAL
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:786-546-5129
Mailing Address - Street 1:5932 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2010
Mailing Address - Country:US
Mailing Address - Phone:786-546-5129
Mailing Address - Fax:954-241-6117
Practice Address - Street 1:5932 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2010
Practice Address - Country:US
Practice Address - Phone:786-546-5129
Practice Address - Fax:954-241-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94972207R00000X
FL3078052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGN339Medicare PIN