Healthcare Provider Details

I. General information

NPI: 1376480723
Provider Name (Legal Business Name): VISTAVERDE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 NW 18TH TER STE 403B
DORAL FL
33172-2610
US

IV. Provider business mailing address

8725 NW 18TH TER STE 403B
DORAL FL
33172-2610
US

V. Phone/Fax

Practice location:
  • Phone: 786-760-8737
  • Fax:
Mailing address:
  • Phone: 786-760-8737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: YIPSANDRA BLANCO CONSUEGRA
Title or Position: OWNER
Credential:
Phone: 786-760-8737