=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538952973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NINOJESUS MEDICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2025
-----------------------------------------------------
Last Update Date | 01/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 W 20TH AVE STE 101
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-1895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-456-4096
-----------------------------------------------------
Fax | 786-828-7995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16400 SW 173RD AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33187-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-456-4096
-----------------------------------------------------
Fax | 786-828-7995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLOS DIAZ VALLADARES
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 305-456-4096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------