Healthcare Provider Details

I. General information

NPI: 1699142398
Provider Name (Legal Business Name): MED ADVANCED CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FONTAINEBLEAU BLVD STE 1-C
MIAMI FL
33172-7018
US

IV. Provider business mailing address

175 FONTAINEBLEAU BLVD STE 1-C
MIAMI FL
33172-7018
US

V. Phone/Fax

Practice location:
  • Phone: 786-294-0889
  • Fax: 786-362-6865
Mailing address:
  • Phone: 786-294-0889
  • Fax: 786-362-6865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENIEL PENA
Title or Position: PRESIDENT
Credential:
Phone: 786-294-0889