Healthcare Provider Details

I. General information

NPI: 1407091069
Provider Name (Legal Business Name): PROFESSIONAL HEALTH MANAGEMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 W FLAGLER ST STE 2M
MIAMI FL
33144-2069
US

IV. Provider business mailing address

8260 W FLAGLER ST STE 2M
MIAMI FL
33144-2069
US

V. Phone/Fax

Practice location:
  • Phone: 305-559-4599
  • Fax: 305-553-0670
Mailing address:
  • Phone: 305-559-4599
  • Fax: 305-553-0670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number562061-3
License Number StateFL

VIII. Authorized Official

Name: MISS GINNA VIVIANA PORTILLA
Title or Position: PRESIDENT
Credential:
Phone: 786-547-2382