Healthcare Provider Details

I. General information

NPI: 1114512670
Provider Name (Legal Business Name): BLUE LAKE MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 03/07/2021
Certification Date: 03/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 W 68TH ST STE 122
HIALEAH FL
33016-5502
US

IV. Provider business mailing address

2360 W 68TH ST STE 122
HIALEAH FL
33016-5502
US

V. Phone/Fax

Practice location:
  • Phone: 305-200-5705
  • Fax: 305-392-1217
Mailing address:
  • Phone: 305-200-5705
  • Fax: 305-392-1217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JORGE GARCIA
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 305-606-0337