=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568046282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI PRIMARY HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2021
-----------------------------------------------------
Last Update Date | 05/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1275 W 47TH PL STE 307
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-722-0999
-----------------------------------------------------
Fax | 786-349-9000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7375 W 18TH AVE
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-333-8623
-----------------------------------------------------
Fax | 786-349-9000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MNG
-----------------------------------------------------
Name | JOSE A VERGARA
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 305-333-8623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------