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General NPI Number Information
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NPI Number | 1043469232
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Entity Type | Organization
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Legal Business Name | PMC JACKSON SOUTH, LLC
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Dates
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Enumeration Date | 09/12/2008
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Last Update Date | 09/12/2008
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Provider Practice Location Address
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Address Line | 9380 SW 150TH ST STE 100
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City | MIAMI
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State | FL
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Zip | 33176-7979
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Country | US
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Telephone | 305-253-2665
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Fax |
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Provider Business Mailing Address
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Address Line | 12550 BISCAYNE BLVD STE 500
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City | NORTH MIAMI
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State | FL
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Zip | 33181-2544
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Country | US
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Telephone | 305-868-7180
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Fax |
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Authorized Official
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Title or Position | MNG MBR
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Name | MR. SPENCER ANGEL
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Credential |
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Telephone | 305-868-7180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | FL
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