Healthcare Provider Details

I. General information

NPI: 1235173402
Provider Name (Legal Business Name): CMS/MCH PRIMARY CARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE COTTAGE #5
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3100 SW 62ND AVE COTTAGE #5
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-2490
  • Fax: 786-624-5790
Mailing address:
  • Phone: 786-624-2490
  • Fax: 786-624-5790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberN/A
License Number State

VIII. Authorized Official

Name: MANUELLA JANVIER-ANGLADE
Title or Position: PROJECT ADMINISTRATOR
Credential: RN
Phone: 786-624-2490