Provider Demographics
NPI:1518248418
Name:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Entity type:Organization
Organization Name:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ILNISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-251-0267
Mailing Address - Street 1:3939 HOLLYWOOD BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6749
Mailing Address - Country:US
Mailing Address - Phone:954-251-0267
Mailing Address - Fax:954-239-7987
Practice Address - Street 1:3939 HOLLYWOOD BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6749
Practice Address - Country:US
Practice Address - Phone:954-251-0267
Practice Address - Fax:754-212-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279510800Medicaid