Healthcare Provider Details

I. General information

NPI: 1548567191
Provider Name (Legal Business Name): FAITH MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 NW 119TH ST SUITE B
NORTH MIAMI FL
33168-2336
US

IV. Provider business mailing address

845 NW 119TH ST SUITE B
NORTH MIAMI FL
33168-2336
US

V. Phone/Fax

Practice location:
  • Phone: 305-685-8001
  • Fax: 305-685-8024
Mailing address:
  • Phone: 305-685-8001
  • Fax: 305-685-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHATARIA BRIDGES-MOSS
Title or Position: OFFICE MANAGER
Credential:
Phone: 305-685-8001