=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225614001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BHEALTHY COMMUNITY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2021
-----------------------------------------------------
Last Update Date | 03/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11402 NW 41ST ST STE 222
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-539-0820
-----------------------------------------------------
Fax | 305-539-0903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11402 NW 41ST ST STE 222
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-539-0820
-----------------------------------------------------
Fax | 305-539-0903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBR
-----------------------------------------------------
Name | ADYS BETANCOURT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-608-8139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------