Healthcare Provider Details

I. General information

NPI: 1992150718
Provider Name (Legal Business Name): WMC HEALTH GROUP OF KISSIMMEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 N JOHN YOUNG PKWY H27
KISSIMMEE FL
34741-7549
US

IV. Provider business mailing address

1380 NE MIAMI GARDENS DR SUITE 210
NORTH MIAMI BEACH FL
33179-4707
US

V. Phone/Fax

Practice location:
  • Phone: 305-692-9009
  • Fax: 305-501-4220
Mailing address:
  • Phone: 305-692-9009
  • Fax: 305-501-4220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME66407
License Number StateFL

VIII. Authorized Official

Name: MR. CARLOS A PEDRAJA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 305-692-9009