MEDICARE: PURE LIFE RENAL OF MIRAMAR, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225671118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE LIFE RENAL OF MIRAMAR, LLC

Provider Business Mailing Address
First Line	:	4000 HOLLYWOOD BLVD STE 300N
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-1242
Country	:	US
Telephone Number	:	330-230-2667
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 S UNIVERSITY DR
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-3005
Country	:	US
Telephone Number	:	954-962-5734
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JEFF FERNANDEZ
Credential	:
Telephone Number	:	954-962-5734

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	08/12/2022

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