Healthcare Provider Details

I. General information

NPI: 1972997682
Provider Name (Legal Business Name): HIALEAH MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4980 W 10TH AVE STE 201
HIALEAH FL
33012-3437
US

IV. Provider business mailing address

4980 W 10TH AVE STE 201
HIALEAH FL
33012-3437
US

V. Phone/Fax

Practice location:
  • Phone: 786-972-5114
  • Fax: 305-456-6194
Mailing address:
  • Phone: 786-972-5114
  • Fax: 305-456-6194

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 Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAUDEL LA O
Title or Position: PRESIDENT
Credential:
Phone: 786-334-6170