Basic Information
| Provider Information | |||||||||
| NPI: | 1770235608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANYAN COMMUNITY HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 BLUE LAGOON DR STE 400 | ||||||||
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| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053986100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4900 W OAKLAND PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333137500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053986100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | ILEANA | ||||||||
| AuthorizedOfficialMiddleName: | RUIZ | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF GRANT DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 3053986132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.