Healthcare Provider Details

I. General information

NPI: 1922523604
Provider Name (Legal Business Name): PURA VIDA MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 W 49TH ST STE 7-12
HIALEAH FL
33012-3456
US

IV. Provider business mailing address

7925 NW 12TH ST STE 201
DORAL FL
33126-1821
US

V. Phone/Fax

Practice location:
  • Phone: 305-698-8432
  • Fax: 305-698-8975
Mailing address:
  • Phone: 305-874-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: NURY CARBAJAL
Title or Position: OWNER
Credential:
Phone: 305-874-3909