Healthcare Provider Details

I. General information

NPI: 1629585906
Provider Name (Legal Business Name): MILLENIUM MEDICAL GROUP CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 SW 97TH AVE SUITE NUMBER A-111
MIAMI FL
33165-3316
US

IV. Provider business mailing address

2740 SW 97TH AVE STE A-111
MIAMI FL
33165-2681
US

V. Phone/Fax

Practice location:
  • Phone: 786-332-4330
  • Fax: 786-332-4109
Mailing address:
  • Phone: 786-332-4330
  • Fax: 786-332-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberARNP9227984
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA64254
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DAMARYS SUAREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-613-0798