MEDICARE: ALTAMIRA COMMUNITY 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417695917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTAMIRA COMMUNITY CENTER LLC

Provider Business Mailing Address
First Line	:	12540 NE 8TH AVE
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-4965
Country	:	US
Telephone Number	:	786-731-6492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 COLONIAL BLVD STE 216
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1026
Country	:	US
Telephone Number	:	786-731-6492
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAYSI HERRERA MARTINEZ
Credential	:	LCSW
Telephone Number	:	786-521-2072

Provider Enumeration Date	:	05/24/2022
Last Update Date	:	05/24/2022

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