MEDICARE: MIRAGE 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1518164342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRAGE MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	85 GRAND CANAL DR STE 310
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2570
Country	:	US
Telephone Number	:	305-264-4375
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 GRAND CANAL DR STE 310
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2570
Country	:	US
Telephone Number	:	305-264-4375
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FRANCESCO VILLALBA
Credential	:
Telephone Number	:	305-264-4375

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	08/22/2020

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