Provider Demographics
NPI:1902061617
Name:CAMILLUS HEALTH CONCERN, INC.
Entity Type:Organization
Organization Name:CAMILLUS HEALTH CONCERN, INC.
Other - Org Name:CAMILLUS HOUSE SHELTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-577-4840
Mailing Address - Street 1:336 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-1616
Mailing Address - Country:US
Mailing Address - Phone:305-577-4840
Mailing Address - Fax:305-373-7431
Practice Address - Street 1:1603 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1415
Practice Address - Country:US
Practice Address - Phone:305-374-1065
Practice Address - Fax:305-372-1402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL680002507Medicaid
FL680002506Medicaid
FL680002506Medicaid
FLK0938Medicare PIN