=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003605452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIETO'S HEALTH CARE COMMUNITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2025
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 N KROME AVE
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-6025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-325-5470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 N KROME AVE
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-6025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-325-5470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADAM M AGUILA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-325-5470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------