=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154276129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOYALTY MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2026
-----------------------------------------------------
Last Update Date | 03/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14145 SW 119TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-720-8562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 343103
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33034-0103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & MANAGING MEMBER
-----------------------------------------------------
Name | CARMEN CARIDAD LEAL DIAZ
-----------------------------------------------------
Credential | APRN, FNP, PMHNP-BC
-----------------------------------------------------
Telephone | 305-244-6868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------