Healthcare Provider Details

I. General information

NPI: 1619352283
Provider Name (Legal Business Name): 125TH STREET NM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 125TH ST
NORTH MIAMI FL
33161-4718
US

IV. Provider business mailing address

505 NE 125TH ST
NORTH MIAMI FL
33161-4718
US

V. Phone/Fax

Practice location:
  • Phone: 954-271-0485
  • Fax:
Mailing address:
  • Phone: 954-271-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPMC20
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RENEE DOUTHAT
Title or Position: CDO
Credential:
Phone: 954-271-0485