MEDICARE: MEDIVITAL HEALTH CENTER 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	261Q00000X	Clinic/Center
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1528855343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIVITAL HEALTH CENTER LLC

Provider Business Mailing Address
First Line	:	10540 NW 78TH ST APT 424
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33178-6089
Country	:	US
Telephone Number	:	305-764-9170
Fax Number	:	833-523-2326

Provider Business Practice Location Address
First Line	:	10550 NW 77TH CT STE 305
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-2071
Country	:	US
Telephone Number	:	786-782-7738
Fax Number	:	833-523-2326

Authorized Official
Title or Position	:	OWNER
Name	:	ADRIANA BAEZ
Credential	:
Telephone Number	:	305-764-9170

Provider Enumeration Date	:	04/23/2025
Last Update Date	:	04/23/2025

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Directions to “MEDIVITAL HEALTH CENTER LLC ” Practice Location

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