=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871710277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH OF SOUTH DADE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10300 SW 216TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33190-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-254-4913
-----------------------------------------------------
Fax | 305-238-7617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10300 SW 216TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33190-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-254-4913
-----------------------------------------------------
Fax | 305-238-7617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH SPECIALIST 1
-----------------------------------------------------
Name | MISS ANTONETTE NATALIE DALBERRY
-----------------------------------------------------
Credential | BA
-----------------------------------------------------
Telephone | 305-278-6445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 302R00000X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------