Healthcare Provider Details

I. General information

NPI: 1770045494
Provider Name (Legal Business Name): LA EDAD PRODIGIOSA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18900 SW 106TH AVE STE 101-102
MIAMI FL
33157-7697
US

IV. Provider business mailing address

1531 NW 29TH AVE
MIAMI FL
33125-2031
US

V. Phone/Fax

Practice location:
  • Phone: 786-445-3463
  • Fax:
Mailing address:
  • Phone: 786-445-3463
  • Fax: 786-701-3994

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: MRS. BELKIS SAAP
Title or Position: PRESIDENT
Credential:
Phone: 786-445-3463