Healthcare Provider Details

I. General information

NPI: 1518803626
Provider Name (Legal Business Name): BONAVITA GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 SW 97TH CT
MIAMI FL
33165-5149
US

IV. Provider business mailing address

4270 SW 97TH CT
MIAMI FL
33165-5149
US

V. Phone/Fax

Practice location:
  • Phone: 305-299-9191
  • Fax:
Mailing address:
  • Phone: 305-299-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JESSICA ULLOA
Title or Position: OWNER
Credential: MSN.ED, RN
Phone: 305-299-9191