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General NPI Number Information
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NPI Number | 1245967587
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Entity Type | Organization
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Legal Business Name | BLUE DIAMOND MEDICAL CENTER CORP.
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Dates
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Enumeration Date | 08/05/2022
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Last Update Date | 04/15/2023
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Provider Practice Location Address
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Address Line | 16430 NW 59TH AVE
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City | MIAMI LAKES
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State | FL
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Zip | 33014-5605
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Country | US
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Telephone | 305-456-0148
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Fax |
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Provider Business Mailing Address
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Address Line | 16430 NW 59TH AVE STE 202
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City | MIAMI LAKES
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State | FL
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Zip | 33014-5605
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Country | US
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Telephone | 305-456-0148
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Fax | 305-456-7559
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Authorized Official
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Title or Position | APRN-FNP
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Name | MARCOS JOSE CARVAJAL
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Credential | APRN
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Telephone | 305-456-0148
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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