Healthcare Provider Details

I. General information

NPI: 1821928847
Provider Name (Legal Business Name): PROVIDA MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 NE 125TH ST
NORTH MIAMI FL
33161-4717
US

IV. Provider business mailing address

428 NE 125TH ST
NORTH MIAMI FL
33161-4717
US

V. Phone/Fax

Practice location:
  • Phone: 305-602-5372
  • Fax:
Mailing address:
  • Phone: 305-602-5372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIO SEPULVEDA
Title or Position: OWNER
Credential:
Phone: 305-602-5372