Healthcare Provider Details

I. General information

NPI: 1174122337
Provider Name (Legal Business Name): LIFE LINE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12595 SW 137TH AVE STE 206
MIAMI FL
33186-4221
US

IV. Provider business mailing address

12595 SW 137TH AVE STE 206
MIAMI FL
33186-4221
US

V. Phone/Fax

Practice location:
  • Phone: 786-474-0541
  • Fax:
Mailing address:
  • Phone: 786-474-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EULOGIO EMILIANO BENITEZ
Title or Position: PRESIDENT
Credential:
Phone: 786-474-0541