NPI |
1194378901 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Entity Type Code |
2 |
The country code in the location address of the provider being identified. |
Employer Identification Number EIN |
|
The telephone number associated with the location address of the provider being identified. |
Provider Organization Name Legal Business Name |
CRISTAL COMMUNITY HEALTH CENTER LLC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider First Line Business Practice Location Address |
931 SW 122ND AVE |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address City Name |
MIAMI |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
FL |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
331842477 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Business Practice Location Address Telephone Number |
7863266308 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Enumeration Date |
7/20/2019 |
|
Last Update Date |
1/28/2022 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Authorized Official Last Name |
GOMEZ |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
MARIA |
The first name of the authorized official. |
Authorized Official Middle Name |
PATRICIA |
The middle name of the authorized official. |
Authorized Official Title or Position |
OWNER |
The title or position of the authorized official. |
Authorized Official Telephone Number |
7863266308 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
2084P0800X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
Healthcare Provider Taxonomy Code 2 |
261QC1500X |
|
Healthcare Provider Primary Taxonomy Switch 2 |
Y |
|
Is Organization Subpart |
N |
|
Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|
NPI Certification Date |
1/28/2022 |
|