La Clinique 300 Inc

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

ME43065 Issued in FL

Legal business name

LA CLINIQUE 300 INC

Practice address

2630 N Andrews Ave
Wilton Manors, FL 33311-2550

Phone

(954) 525-4900

Fax

(954) 396-3110

NPI assigned

Jul 22, 2015

Organization subpart

Yes

Parent organization

JOSEPH FANFAN JR MD PAAs reported in NPPES

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

Authorized official

Name

Dr. Joseph Fanfan, MDNPI 1265608616

Title

President

Phone

(954) 525-4900

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• JOSEPH FANFAN JR MD PA Doing business as

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Part of

La Clinique 300 Inc

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Joseph Fanfan Jr., M.D.

  • Family Medicine Physician
  • Wilton Manors, FL
  • NPI 1265608616
  Medicare reassignment Authorized official

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

{
    "created_epoch": "1437523200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1462752000000",
    "number": "1689059453",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2630 N ANDREWS AVE",
            "city": "WILTON MANORS",
            "state": "FL",
            "postal_code": "333112550",
            "telephone_number": "954-525-4900",
            "fax_number": "954-396-3110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2630 N ANDREWS AVE",
            "city": "WILTON MANORS",
            "state": "FL",
            "postal_code": "333112550",
            "telephone_number": "954-525-4900",
            "fax_number": "954-396-3110"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA CLINIQUE 300 INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "JOSEPH FANFAN JR MD PA",
        "enumeration_date": "2015-07-22",
        "last_updated": "2016-05-09",
        "status": "A",
        "authorized_official_last_name": "FANFAN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "954-525-4900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "FL",
            "license": "ME43065",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "068166100",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "JOSEPH FANFAN JR MD PA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Bright Komla Edem Kofi-Nyarko, PHARMD
• Wayne Kossman, LMHC
• Vanessa Leigh Koutalidis, DC
• William John Krantz, P.A.
• George Thomas Kress, RPH
• Richard Dexter Ladner, RPH
• Marc Lalonde, PTA, CKTP
• Lampasas, Inc
• Jason William Lane, M.D.
• Cub Joseph Larkin, M.S., NCC

• Clinic/Center in Wilton Manors, FL
• Providers in Wilton Manors, FL by specialty
• Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 9, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.