Provider Demographics
NPI:1902580699
Name:FENIX MEDICAL CLINIC, CORP.
Entity Type:Organization
Organization Name:FENIX MEDICAL CLINIC, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-824-2023
Mailing Address - Street 1:4701 W 4TH AVE.
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:305-824-2023
Mailing Address - Fax:786-814-5703
Practice Address - Street 1:4701 W 4TH AVE.
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:786-542-9702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty