Basic Information
| Provider Information | |||||||||
| NPI: | 1205233772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANYAN COMMUNITY HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | BANYAN HEALTH SYSTEMS, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 3057572387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 W FLAGLER ST | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331341604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057743400 | ||||||||
| FaxNumber: | 3054420482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2014 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | CARRODEGUAS | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3053986100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 013881903 | 05 | FL | MEDICAID |