Provider Demographics
NPI:1811561186
Name:MYCLINIC WELLNESS CENTER CORP
Entity type:Organization
Organization Name:MYCLINIC WELLNESS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:UBEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-902-8137
Mailing Address - Street 1:14201 SW 120TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7663
Mailing Address - Country:US
Mailing Address - Phone:305-902-8137
Mailing Address - Fax:
Practice Address - Street 1:14201 SW 120TH ST STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7663
Practice Address - Country:US
Practice Address - Phone:305-902-8137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)