Basic Information
| Provider Information | |||||||||
| NPI: | 1104247188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANYAN COMMUNITY HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 BLUE LAGOON DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053986100 | ||||||||
| FaxNumber: | 3053986099 | ||||||||
| Practice Location | |||||||||
| Address1: | 3733 W FLAGLER ST | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331341601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053986100 | ||||||||
| FaxNumber: | 3053986099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | CARRODEGUAS | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3053986100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 013881900 | 05 | FL | MEDICAID | 013881911 | 05 | FL | MEDICAID | 013881901 | 05 | FL | MEDICAID |