Basic Information
| Provider Information | |||||||||
| NPI: | 1902195191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE OF PREVENTIVE MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 W 47TH PL | ||||||||
| Address2: | SUITE 422 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056762300 | ||||||||
| FaxNumber: | 8886010076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 W 47TH PL | ||||||||
| Address2: | SUITE 422 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056762300 | ||||||||
| FaxNumber: | 8886010076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | OTNIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3056762300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | ARNP3081082 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 308614300 | 05 | FL | MEDICAID |