Healthcare Provider Details

I. General information

NPI: 1902856933
Provider Name (Legal Business Name): COLUMBUS CLINICAL SVC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SW 107TH AVE
MIAMI FL
33174-1415
US

IV. Provider business mailing address

15 SW 107TH AVE
MIAMI FL
33174-1415
US

V. Phone/Fax

Practice location:
  • Phone: 305-559-5759
  • Fax: 305-559-5772
Mailing address:
  • Phone: 305-559-5759
  • Fax: 305-559-5772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA V CANO
Title or Position: MANAGER/OWNER
Credential:
Phone: 305-559-5759