MEDICARE: OUR GOLDEN MEDICAL CENTER

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	332900000X	Non-Pharmacy Dispensing Site	ME81667	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1019113	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1447366208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR GOLDEN MEDICAL CENTER

Provider Business Mailing Address
First Line	:	12781 SW 42ND ST
Second Line	:	STE H
City	:	MIAMI
State	:	FL
Zip	:	33175-3437
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12781 SW 42ND ST
Second Line	:	STE H
City	:	MIAMI
State	:	FL
Zip	:	33175-3437
Country	:	US
Telephone Number	:	305-229-3990
Fax Number	:

Authorized Official
Title or Position	:	MANAGED CARE SPECIALIST
Name	:	DIRENDIA SHACKELFORD
Credential	:
Telephone Number	:	800-654-0889

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	08/22/2020

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Directions to “OUR GOLDEN MEDICAL CENTER ” Practice Location

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