| Organization Name: | MED LAKE CENTER |
| NPI Number: | 1063814465 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARIA GISSELLE BOU (CEO MANAGER) |
| Mailing Address: | 16371 Nw 67th Ave Miami Lakes |
| State: | FL US |
| Postal Code: | 330146044 |
| Phone Number: | 7863324991 |
| Fax Number: | 7864092037 |
| NPI Enumeration Date: | 09/17/2014 |
| NPI Last Update Date: | 09/17/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 302R00000X |
| License Number: | MD 62905 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Managed Care Organizations |
| Taxonomy Classification: | Health Maintenance Organization |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A form of health insurance in which its members prepay a premium for the HMO |