Provider Demographics
NPI:1871963520
Name:TGWC DETOX
Entity type:Organization
Organization Name:TGWC DETOX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-671-3267
Mailing Address - Street 1:16565 NE TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33162
Mailing Address - Country:US
Mailing Address - Phone:305-944-1516
Mailing Address - Fax:
Practice Address - Street 1:16565 NE TH AVENUE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:305-944-1516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5691133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLND5691OtherDIETITIAN/NUTRITIONIST