Healthcare Provider Details

I. General information

NPI: 1386041408
Provider Name (Legal Business Name): LCC MEDICAL GROUP, CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NW 72ND AVE STE 620
MIAMI FL
33126-1921
US

IV. Provider business mailing address

1150 NW 72ND AVE STE 620
MIAMI FL
33126-1921
US

V. Phone/Fax

Practice location:
  • Phone: 305-403-2221
  • Fax: 305-403-2262
Mailing address:
  • Phone: 305-403-2221
  • Fax: 305-403-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberARNP9311339
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9311339
License Number StateFL

VIII. Authorized Official

Name: MS. VIVIAN SALINAS
Title or Position: PRESIDENT
Credential: ARNP
Phone: 305-403-2221