MEDICARE: MEDIMPACT CLINICAL AND INVESTIGATIONAL 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	261Q00000X	Clinic/Center
2	261QR1100X	Research Clinic/Center

General Provider Information

NPI Number	:	1962171710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIMPACT CLINICAL AND INVESTIGATIONAL CENTER

Provider Business Mailing Address
First Line	:	31 TAMIAMI CANAL RD
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2538
Country	:	US
Telephone Number	:	786-608-1473
Fax Number	:	305-264-2909

Provider Business Practice Location Address
First Line	:	31 TAMIAMI CANAL RD
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2538
Country	:	US
Telephone Number	:	786-608-1473
Fax Number	:	305-264-2909

Authorized Official
Title or Position	:	CEO
Name	:	MR. ALFREDO MARTIN
Credential	:
Telephone Number	:	786-608-1473

Provider Enumeration Date	:	09/07/2021
Last Update Date	:	09/07/2021

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