Organization
ILLUMINA MEDICAL GROUP SPECIALTY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ANGEL ANDRES MONGEOTTI (EXECUTIVE DIRECTOR OF FINANCE)
(305) 254-8900
Entity
Organization
Contact information
Practice address
1914 NW 84TH AVE, DORAL, FL 33126
(305) 254-8900
(305) 254-8902
Mailing address
1914 NW 84TH AVE, DORAL, FL 33126-1030
(305) 254-8900
(305) 254-8902
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
261Q00000X
Clinic/Center
Primary
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
261QM2500X
Medical Specialty Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
L17000260851
STATE DOCUMENT NUMBER
FL
Enumeration date
01/17/2018
Last updated
07/27/2018
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