Healthcare Provider Details

I. General information

NPI: 1669832341
Provider Name (Legal Business Name): PURE AGE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1054 GATEWAY BLVD SUITE 103
BOYNTON BEACH FL
33426-8301
US

IV. Provider business mailing address

1054 GATEWAY BLVD SUITE 103
BOYNTON BEACH FL
33426-8301
US

V. Phone/Fax

Practice location:
  • Phone: 561-847-4654
  • Fax: 561-847-4956
Mailing address:
  • Phone: 561-847-4654
  • Fax: 561-847-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9106969
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License NumberME83769
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberME83769
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2083T0002X
TaxonomyMedical Toxicology (Preventive Medicine) Physician
License NumberME83769
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number10D2100646
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME83769
License Number StateFL

VIII. Authorized Official

Name: MR. KARL E VAETH
Title or Position: OWNER/MANAGING PARTNER
Credential:
Phone: 561-225-9922