Healthcare Provider Details

I. General information

NPI: 1174695449
Provider Name (Legal Business Name): PREMIUM CARE DOCTORS CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 E 4TH AVE
HIALEAH FL
33010-3115
US

IV. Provider business mailing address

1816 E 4TH AVE
HIALEAH FL
33010-3115
US

V. Phone/Fax

Practice location:
  • Phone: 305-805-0012
  • Fax: 305-883-9003
Mailing address:
  • Phone: 305-805-0012
  • Fax: 305-883-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL ALFREDO GALGUERA
Title or Position: PRESIDENT
Credential: MD
Phone: 305-805-0012