Healthcare Provider Details

I. General information

NPI: 1134086739
Provider Name (Legal Business Name): ELEMENTAL LIVING CA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56553 HIGHWAY 371 SUITE B1
ANZA CA
92539
US

IV. Provider business mailing address

301 ALMERIA AVE STE 240
CORAL GABLES FL
33134-5822
US

V. Phone/Fax

Practice location:
  • Phone: 954-231-5484
  • Fax: 239-379-4385
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ABBEY HERNANDEZ
Title or Position: CEO
Credential: DC
Phone: 714-326-7647