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General NPI Number Information
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NPI Number | 1457760712
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Entity Type | Organization
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Legal Business Name | PROVIDENCE COMMUNITY CENTER LLC
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Dates
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Enumeration Date | 08/11/2014
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Last Update Date | 08/11/2014
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Provider Practice Location Address
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Address Line | 5932 NE 2ND AVE
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City | MIAMI
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State | FL
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Zip | 33137-2010
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Country | US
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Telephone | 786-546-5129
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Fax | 954-241-6117
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Provider Business Mailing Address
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Address Line | 5932 NE 2ND AVE
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City | MIAMI
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State | FL
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Zip | 33137-2010
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Country | US
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Telephone | 786-546-5129
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Fax | 954-241-6117
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. JULINA T DORVAL
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Credential | ARNP
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Telephone | 786-546-5129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME94972
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3078052
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License Number State | FL
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