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Organization
125TH STREET NM CORP
Active
Organization
125TH STREET NM CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RENEE DOUTHAT (CDO)
(954) 271-0485
Entity
Organization
Contact information
Practice address
505 NE 125TH ST, NORTH MIAMI, FL 33161-4718
(954) 271-0485
Mailing address
505 NE 125TH ST, NORTH MIAMI, FL 33161-4718
(954) 271-0485
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
—
—
2084P0802X
Addiction Psychiatry Physician
Primary
—
—
261QP2000X
Physical Therapy Clinic/Center
PMC20
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
HCC8934
ACHA
FL
Enumeration date
07/24/2015
Last updated
04/07/2016
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