Healthcare Provider Details

I. General information

NPI: 1548359532
Provider Name (Legal Business Name): IDEAL MEDICAL CENTER OF HIALEAH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 W 20 AVE SUITE 105
HIALEAH FL
33012
US

IV. Provider business mailing address

11782 SW 92 TER
MIAMI FL
33186
US

V. Phone/Fax

Practice location:
  • Phone: 305-557-2277
  • Fax:
Mailing address:
  • Phone: 305-271-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberHCC6717
License Number StateFL

VIII. Authorized Official

Name: OCTAVIO ALEXIS BRAVO
Title or Position: COO
Credential:
Phone: 305-557-2277