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General NPI Number Information
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NPI Number | 1114512670
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Entity Type | Organization
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Legal Business Name | BLUE LAKE MEDICAL CENTER, INC.
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Dates
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Enumeration Date | 03/07/2021
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Last Update Date | 03/07/2021
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Provider Practice Location Address
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Address Line | 2360 W 68TH ST STE 122
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City | HIALEAH
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State | FL
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Zip | 33016-5502
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Country | US
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Telephone | 305-200-5705
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Fax | 305-392-1217
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Provider Business Mailing Address
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Address Line | 2360 W 68TH ST STE 122
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City | HIALEAH
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State | FL
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Zip | 33016-5502
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Country | US
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Telephone | 305-200-5705
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Fax | 305-392-1217
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Authorized Official
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Title or Position | CREDENTIALING DIRECTOR
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Name | JORGE GARCIA
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Credential |
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Telephone | 305-606-0337
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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 |
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