MEDICARE: MIAMI MEDICAL & WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME87037	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ID353A	OTHER	FL	MEDICARE PTAN
2	11761Q	OTHER	FL	MEDICARE PTAN DUM
3	E6931S	OTHER	FL	MEDICARE PTAN ALO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	GK944Y	OTHER	FL	PTAN DE L

General Provider Information

NPI Number	:	1407271844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI MEDICAL & WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	1200 ALTON RD
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33139-3810
Country	:	US
Telephone Number	:	305-534-0076
Fax Number	:	305-532-5868

Provider Business Practice Location Address
First Line	:	551 E 49TH ST
Second Line	:	SUITE 1-8
City	:	HIALEAH
State	:	FL
Zip	:	33013-1904
Country	:	US
Telephone Number	:	305-532-3923
Fax Number	:	305-532-5868

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RODOLFO DUMENIGO JR.
Credential	:	M.D
Telephone Number	:	305-534-0076

Provider Enumeration Date	:	02/21/2014
Last Update Date	:	07/13/2015

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Directions to “MIAMI MEDICAL & WELLNESS CENTER LLC ” Practice Location

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