| Entity Name: | FRAGA MEDICAL CENTER INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 25 Jan 1993 (32 years ago) |
| Document Number: | P93000005677 |
| FEI/EIN Number | 650376033 |
| Mail Address: | 5590 W 20 Ave, Hialeah, FL, 33016, US |
| Address: | 11865 CORAL WAY, MIAMI, FL, 33175, US |
| ZIP code: | 33175 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1871698027 | 2006-09-13 | 2018-03-17 | 4141 SW 6TH ST, CORAL GABLES, FL, 331342057, US | 11865 CORAL WAY, SUITE B-7, MIAMI, FL, 331752400, US | |||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 305-443-5031 |
| Phone | +1 305-220-6128 |
| Fax | 3052272855 |
Authorized person
| Name | DR. RENE CASANOVA |
| Role | MEDICAL DIRECTOR |
| Phone | 9548167795 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | ACN961 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2080A0000X - Pediatric Adolescent Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208D00000X - General Practice Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 279234600 |
| State | FL |
| Issuer | MEDICAID |
| Number | 054135400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BEILLY BRADFORD J | Agent | 1144 SE 3RD AVE, FORT LAUDERDALE, FL, 33316 |
| Name | Role | Address |
|---|---|---|
| CASANOVA RENE | Director | 1144 SE 3RD AVENUE, FORT LAUDERDALE, FL, 33316 |
| Name | Role | Address |
|---|---|---|
| CASANOVA RENE | President | 1144 SE 3RD AVENUE, FORT LAUDERDALE, FL, 33316 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G19000045892 | PRIMECARE FAMILY CENTERS | EXPIRED | 2019-04-11 | 2024-12-31 | No data | 7765 NW 48 STREET, SUITE 300, DORAL, FL, 33166 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2018-11-16 | No data | No data |
| CANCEL ADM DISS/REV | 2007-10-09 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2007-09-14 | No data | No data |
| AMENDMENT | 2007-08-30 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
