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General NPI Number Information
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NPI Number | 1083379564
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Entity Type | Organization
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Legal Business Name | SUPRA MEDICAL GROUP II, LLC
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Dates
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Enumeration Date | 11/01/2021
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Last Update Date | 11/01/2021
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Provider Practice Location Address
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Address Line | 10300 SW 72ND ST STE 101
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City | MIAMI
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State | FL
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Zip | 33173-3038
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Country | US
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Telephone | 305-200-5210
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Fax | 305-200-5780
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Provider Business Mailing Address
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Address Line | 10300 SW 72ND ST STE 101
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City | MIAMI
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State | FL
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Zip | 33173-3038
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Country | US
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Telephone | 305-200-5210
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Fax | 305-200-5780
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Authorized Official
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Title or Position | CEO
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Name | KLEYDSON DA SILVA
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Credential |
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Telephone | 305-200-5210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #3
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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