Premium Medical Center Corp

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

PREMIUM MEDICAL CENTER CORP

Practice address

6405 NW 36TH St Ste 111
Virginia Gardens, FL 33166-6977

Phone

(786) 334-5047

Fax

(786) 334-5048

NPI assigned

Jun 13, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Deivys Gonzalez Oliva

Title

Authorized Official

Phone

(786) 334-5047

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1560384000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736812800000",
    "number": "1053971937",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6405 NW 36TH ST STE 111",
            "city": "VIRGINIA GARDENS",
            "state": "FL",
            "postal_code": "331666977",
            "telephone_number": "786-334-5047",
            "fax_number": "786-334-5048"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6405 NW 36TH ST STE 111",
            "city": "VIRGINIA GARDENS",
            "state": "FL",
            "postal_code": "331666977",
            "telephone_number": "786-334-5047",
            "fax_number": "786-334-5048"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIUM MEDICAL CENTER CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-13",
        "last_updated": "2025-01-14",
        "certification_date": "2025-01-14",
        "status": "A",
        "authorized_official_last_name": "GONZALEZ OLIVA",
        "authorized_official_first_name": "DEIVYS",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "786-334-5047",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinic/Center in Virginia Gardens, FL
• Providers in Virginia Gardens, FL by specialty
• Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.