Healthcare Provider Details

I. General information

NPI: 1902177280
Provider Name (Legal Business Name): FAITH MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 W 49 STREET SUITE 103
HIALEAH FL
33012
US

IV. Provider business mailing address

1840 W 49 STREET SUITE 103
HIALEAH FL
33012
US

V. Phone/Fax

Practice location:
  • Phone: 305-634-9742
  • Fax: 605-634-9744
Mailing address:
  • Phone: 305-634-9742
  • Fax: 605-634-9744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME82456
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14991
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA44576
License Number StateFL

VIII. Authorized Official

Name: MR. RAFAEL DEULOFEU
Title or Position: PRESIDENT
Credential: OWNER
Phone: 305-634-9742