Healthcare Provider Details

I. General information

NPI: 1790455053
Provider Name (Legal Business Name): MI TIERRA MEDICAL GROUP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14201 SW 120TH ST STE 110
MIAMI FL
33186-7662
US

IV. Provider business mailing address

14201 SW 120TH ST STE 110
MIAMI FL
33186-7662
US

V. Phone/Fax

Practice location:
  • Phone: 786-238-7492
  • Fax: 786-238-7426
Mailing address:
  • Phone: 786-238-7492
  • Fax: 786-238-7426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOAN RODRIGUEZ
Title or Position: PRESIDENT
Credential:
Phone: 786-238-3054