Healthcare Provider Details

I. General information

NPI: 1710485255
Provider Name (Legal Business Name): EXCELSIOR MEDICAL HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18441 NW 2ND AVE STE 103
MIAMI GARDENS FL
33169-4517
US

IV. Provider business mailing address

1441 NW 204TH ST
MIAMI FL
33169-2452
US

V. Phone/Fax

Practice location:
  • Phone: 305-650-1158
  • Fax:
Mailing address:
  • Phone: 786-564-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberPA9104039
License Number StateFL

VIII. Authorized Official

Name: MRS. GERALDA PHANOR FLEURANVIL
Title or Position: CEO
Credential: PA-C
Phone: 786-564-9438