| Providence Community Center Llc | |
|
5932 Ne 2nd Ave Miami FL 33137-2010 | |
| (786) 546-5129 | |
| (954) 241-6117 |
| Full Name | Providence Community Center Llc |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 5932 Ne 2nd Ave, Miami, Florida |
| Authorized Official Name and Position | Julina T Dorval (MANAGING MEMBER) |
| Authorized Official Contact | 7865465129 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Community Center Llc 5932 Ne 2nd Ave Miami FL 33137-2010 Ph: (786) 546-5129 | Providence Community Center Llc 5932 Ne 2nd Ave Miami FL 33137-2010 Ph: (786) 546-5129 |
| NPI Number | 1457760712 |
|---|---|
| Provider Enumeration Date | 08/11/2014 |
| Last Update Date | 08/11/2014 |
| Medicare PECOS PAC ID | 2860715778 |
|---|---|
| Medicare Enrollment ID | O20141230000694 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1457760712 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | ME94972 (Florida) | Secondary |
| 363LF0000X | Nurse Practitioner - Family | 3078052 (Florida) | Primary |
| Provider Name | Alphonse G Dufreny |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1356311922 PECOS PAC ID: 5890683395 Enrollment ID: I20040308000074 |
| Provider Name | Julina T Dorval |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1386918217 PECOS PAC ID: 7214186436 Enrollment ID: I20121003000835 |
| Provider Name | Saul Ernest |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174975684 PECOS PAC ID: 2961780952 Enrollment ID: I20180618000615 |
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