Healthcare Provider Details

I. General information

NPI: 1659132611
Provider Name (Legal Business Name): MANGROVE HEALTH PROVIDER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11373 SW 211TH ST
MIAMI FL
33189-2245
US

IV. Provider business mailing address

5966 S DIXIE HWY STE 300
SOUTH MIAMI FL
33143-5177
US

V. Phone/Fax

Practice location:
  • Phone: 954-699-7766
  • Fax:
Mailing address:
  • Phone: 305-606-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELENA C CASTANEDA
Title or Position: CEO
Credential:
Phone: 305-606-4603