Provider Demographics
NPI:1285298521
Name:PROMED HEALTHCARE CLINIC LLC
Entity type:Organization
Organization Name:PROMED HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAGALY
Authorized Official - Middle Name:PASCAL
Authorized Official - Last Name:TRAVIESO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:786-580-1859
Mailing Address - Street 1:11400 W FLAGLER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-4007
Mailing Address - Country:US
Mailing Address - Phone:305-548-1118
Mailing Address - Fax:786-558-5697
Practice Address - Street 1:11400 W FLAGLER ST STE 202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-4007
Practice Address - Country:US
Practice Address - Phone:305-548-1118
Practice Address - Fax:786-558-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT612540715810OtherARNP9240892