Healthcare Provider Details

I. General information

NPI: 1063417483
Provider Name (Legal Business Name): PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15055 NW 27 AVENUE
OPA-LOCKA FL
33054-3365
US

IV. Provider business mailing address

P.O. BOX 12493
MIAMI FL
33101-2493
US

V. Phone/Fax

Practice location:
  • Phone: 305-466-2800
  • Fax: 786-466-2748
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number8511
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number8511
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number8511
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number8511
License Number StateFL

VIII. Authorized Official

Name: MR. MARK T KNIGHT
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 305-585-7979