Healthcare Provider Details

I. General information

NPI: 1760470652
Provider Name (Legal Business Name): ST. JOHN CLINIC MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 NW 29TH ST
MIAMI FL
33127-3929
US

IV. Provider business mailing address

161 NW 29TH ST
MIAMI FL
33127-3929
US

V. Phone/Fax

Practice location:
  • Phone: 305-576-0231
  • Fax: 305-573-1458
Mailing address:
  • Phone: 305-576-0231
  • Fax: 305-573-1458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. REYNALDO CRUZ
Title or Position: CEO
Credential:
Phone: 305-576-0231