MEDICARE: LA SAGRADA FAMILIA MEDICAL CENTER INC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1508468869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA SAGRADA FAMILIA MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	9600 NW 25TH ST STE 3C
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33172-1416
Country	:	US
Telephone Number	:	786-615-2843
Fax Number	:

Provider Business Practice Location Address
First Line	:	9600 NW 25TH ST STE 3C
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33172-1416
Country	:	US
Telephone Number	:	754-800-2160
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AILEN CRUZ BERGON
Credential	:
Telephone Number	:	786-615-2843

Provider Enumeration Date	:	11/12/2020
Last Update Date	:	05/19/2021

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