Provider Demographics
NPI:1285056663
Name:SUPRA MEDICAL GROUP
Entity type:Organization
Organization Name:SUPRA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-485-1532
Mailing Address - Street 1:201 NW 70TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2369
Mailing Address - Country:US
Mailing Address - Phone:305-485-1532
Mailing Address - Fax:305-485-1534
Practice Address - Street 1:201 NW 70TH AVE STE A
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2369
Practice Address - Country:US
Practice Address - Phone:305-485-1532
Practice Address - Fax:305-485-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC10035OtherAHCA