Healthcare Provider Details

I. General information

NPI: 1588035794
Provider Name (Legal Business Name): LIFE MED CENTER ASSOC CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 07/21/2022
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 CORAL WAY STE 404
MIAMI FL
33155-1693
US

IV. Provider business mailing address

434 SW 12TH AVE STE 300
MIAMI FL
33130-2433
US

V. Phone/Fax

Practice location:
  • Phone: 786-762-2474
  • Fax: 786-953-5613
Mailing address:
  • Phone: 786-762-2474
  • Fax: 786-953-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. LUIS O GASCA
Title or Position: PRESIDENT
Credential: MD
Phone: 786-762-2474