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General NPI Number Information
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NPI Number | 1194129684
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Entity Type | Organization
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Legal Business Name | FOR LIFE MEDICAL INC
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Dates
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Enumeration Date | 10/13/2014
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | 4355 W 16TH AVE STE 207A
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City | HIALEAH
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State | FL
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Zip | 33012-7669
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Country | US
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Telephone | 786-254-7636
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Fax | 786-254-7162
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Provider Business Mailing Address
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Address Line | 4355 W 16TH AVE STE 207A
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City | HIALEAH
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State | FL
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Zip | 33012-7669
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Country | US
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Telephone | 786-254-7636
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Fax | 786-254-7162
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Authorized Official
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Title or Position | P
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Name | MARA T VENTURA
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Credential | M.A.
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Telephone | 786-254-7636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | OS12833
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License Number State | FL
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