MEDICARE: POLICLINICO SANTA CLARA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1811965395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLICLINICO SANTA CLARA INC

Provider Business Mailing Address
First Line	:	2742 SW 8TH ST
Second Line	:	SUITE 19
City	:	MIAMI
State	:	FL
Zip	:	33135-4650
Country	:	US
Telephone Number	:	305-631-9903
Fax Number	:	305-649-6364

Provider Business Practice Location Address
First Line	:	2742 SW 8TH ST
Second Line	:	SUITE 19
City	:	MIAMI
State	:	FL
Zip	:	33135-4650
Country	:	US
Telephone Number	:	305-631-9903
Fax Number	:	305-649-6364

Authorized Official
Title or Position	:	OWNER
Name	:	HENRY LORA
Credential	:	MD
Telephone Number	:	305-631-9903

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	09/22/2008

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