Provider Demographics
NPI:1174990915
Name:FARDALES MEDICAL CENTER INC
Entity type:Organization
Organization Name:FARDALES MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARICELA
Authorized Official - Middle Name:DIANEXI
Authorized Official - Last Name:FARDALES
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:305-400-9702
Mailing Address - Street 1:8051 W 24TH AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5596
Mailing Address - Country:US
Mailing Address - Phone:305-400-9702
Mailing Address - Fax:305-735-7542
Practice Address - Street 1:8051 W 24TH AVE STE 9
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5596
Practice Address - Country:US
Practice Address - Phone:305-400-9702
Practice Address - Fax:305-397-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103093261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004570500Medicaid