Healthcare Provider Details

I. General information

NPI: 1194330340
Provider Name (Legal Business Name): GREEN MOUNTAIN MED CON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8175 NW 12TH ST STE 221
DORAL FL
33126-1828
US

IV. Provider business mailing address

7925 NW 12TH ST STE 325
DORAL FL
33126-1846
US

V. Phone/Fax

Practice location:
  • Phone: 786-580-4957
  • Fax: 786-773-5259
Mailing address:
  • Phone: 786-580-4957
  • Fax: 786-773-5259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLAUDIA FUNDORA
Title or Position: PRESIDENT
Credential:
Phone: 786-571-2788