Provider Demographics
NPI:1194330340
Name:GREEN MOUNTAIN MED CON, INC
Entity type:Organization
Organization Name:GREEN MOUNTAIN MED CON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNDORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-571-2788
Mailing Address - Street 1:7925 NW 12TH ST STE 325
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1846
Mailing Address - Country:US
Mailing Address - Phone:786-580-4957
Mailing Address - Fax:786-773-5259
Practice Address - Street 1:7925 NW 12TH ST STE 325
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1846
Practice Address - Country:US
Practice Address - Phone:786-571-2788
Practice Address - Fax:786-773-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty