Basic Information
| Provider Information | |||||||||
| NPI: | 1932872637 | ||||||||
| 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: | 1061 W OAKLAND PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | WILTON MANORS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333111600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057743300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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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: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 014042600 | 05 | FL | MEDICAID |