Healthcare Provider Details

I. General information

NPI: 1275202392
Provider Name (Legal Business Name): BUENA VIDA WELLNESS CENTER, CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2021
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12769 SW 42ND ST STE 28-32
MIAMI FL
33175-3429
US

IV. Provider business mailing address

12769 SW 42ND ST STE 28-32
MIAMI FL
33175-3429
US

V. Phone/Fax

Practice location:
  • Phone: 305-576-9999
  • Fax: 305-722-3586
Mailing address:
  • Phone: 305-576-9999
  • Fax: 305-722-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCOS DIAZ
Title or Position: PRESIDENT
Credential: RN
Phone: 305-335-3638