Club Community Care LLC

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

CLUB COMMUNITY CARE LLC

Practice address

164 NW Madison St
Lake City, FL 32055-3904

Phone

(786) 587-9814

NPI assigned

Dec 10, 2020

Organization subpart

No

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

Authorized official

Name

Damary Diaz Hernandez

Title

President

Phone

(786) 497-1134

Specialties & licenses 2

Addresses

Locations

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

{
    "created_epoch": "1607558400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1607558400000",
    "number": "1982200382",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "164 NW MADISON ST",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320553904",
            "telephone_number": "786-587-9814"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "164 NW MADISON ST",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320553904",
            "telephone_number": "786-587-9814"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLUB COMMUNITY CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-10",
        "last_updated": "2020-12-10",
        "certification_date": "2020-12-10",
        "status": "A",
        "authorized_official_last_name": "DIAZ HERNANDEZ",
        "authorized_official_first_name": "DAMARY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "786-497-1134"
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Community/Behavioral Health Agency in Lake City, FL
• Providers in Lake City, FL by specialty
• Community/Behavioral Health Agency in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2020; 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.