Healthcare Provider Details

I. General information

NPI: 1073933610
Provider Name (Legal Business Name): XTRA HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 SW 122ND AVE
MIAMI FL
33184-2406
US

IV. Provider business mailing address

951 SW 122ND AVE
MIAMI FL
33184-2406
US

V. Phone/Fax

Practice location:
  • Phone: 305-793-4234
  • Fax:
Mailing address:
  • Phone: 305-793-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMA42484
License Number StateFL

VIII. Authorized Official

Name: JORGE A GONZALEZ
Title or Position: PRESIDENT
Credential: MT
Phone: 305-793-4234