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General NPI Number Information
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NPI Number | 1174990915
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Entity Type | Organization
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Legal Business Name | FARDALES MEDICAL CENTER INC
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Dates
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Enumeration Date | 08/27/2015
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Last Update Date | 05/14/2021
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Provider Practice Location Address
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Address Line | 8051 W 24TH AVE STE 9
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City | HIALEAH
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State | FL
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Zip | 33016-5596
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Country | US
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Telephone | 305-400-9702
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Fax | 305-397-2165
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Provider Business Mailing Address
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Address Line | 8051 W 24TH AVE STE 9
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City | HIALEAH
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State | FL
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Zip | 33016-5596
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Country | US
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Telephone | 305-400-9702
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Fax | 305-735-7542
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARICELA DIANEXI FARDALES
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Credential | P.A.
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Telephone | 305-400-9702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | PA9103093
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License Number State | FL
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