Healthcare Provider Details

I. General information

NPI: 1144710146
Provider Name (Legal Business Name): EDEN MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8302 NW 103RD ST STE 201
HIALEAH GARDENS FL
33016
US

IV. Provider business mailing address

8302 NW 103RD ST STE 201
HIALEAH GARDENS FL
33016-4698
US

V. Phone/Fax

Practice location:
  • Phone: 786-374-9928
  • Fax:
Mailing address:
  • Phone: 786-651-2442
  • Fax: 786-528-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SURISADAY RONES
Title or Position: MANAGER
Credential:
Phone: 786-651-2442