=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154757466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE LIFE MEDICAL GROUP , INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2013
-----------------------------------------------------
Last Update Date | 09/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 GRAND CANAL DR SUITE 104
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-262-0298
-----------------------------------------------------
Fax | 305-262-1253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 GRAND CANAL DR SUITE 104
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-262-0298
-----------------------------------------------------
Fax | 305-262-1253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS BARBARA GONZALEZ
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 305-262-0298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | MA67461
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------