Healthcare Provider Details

I. General information

NPI: 1598461105
Provider Name (Legal Business Name): AMIGOS SOCIAL CLUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5824 W 20TH AVE
HIALEAH FL
33016-2603
US

IV. Provider business mailing address

5824 W 20TH AVE
HIALEAH FL
33016-2603
US

V. Phone/Fax

Practice location:
  • Phone: 786-542-1819
  • Fax: 305-960-7529
Mailing address:
  • Phone: 786-542-1819
  • Fax: 305-960-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAYSA GUERRERO
Title or Position: OWNER
Credential:
Phone: 305-389-6913