Healthcare Provider Details

I. General information

NPI: 1902944861
Provider Name (Legal Business Name): PORT OF MIAMI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N AMERICA WAY STE 150
MIAMI FL
33132-2017
US

IV. Provider business mailing address

3607 OLD CONEJO RD
THOUSAND OAKS CA
91320-2123
US

V. Phone/Fax

Practice location:
  • Phone: 305-358-4265
  • Fax:
Mailing address:
  • Phone: 805-375-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberAP0172887
License Number StateFL

VIII. Authorized Official

Name: DR. IRWIN POTASH
Title or Position: PHYSICIAN
Credential:
Phone: 805-358-4265