MEDICARE: PURE AGE MANAGEMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9106969	FL
2	207RI0001X	Clinical & Laboratory Immunology (Internal Medicine) Physician	ME83769	FL
3	2083B0002X	Obesity Medicine (Preventive Medicine) Physician	ME83769	FL
4	2083T0002X	Medical Toxicology (Preventive Medicine) Physician	ME83769	FL
5	291U00000X	Clinical Medical Laboratory	10D2100646	FL
6	207R00000X	Internal Medicine Physician	ME83769	FL

General Provider Information

NPI Number	:	1669832341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE AGE MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	1054 GATEWAY BLVD
Second Line	:	SUITE 103
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8301
Country	:	US
Telephone Number	:	561-847-4654
Fax Number	:	561-847-4956

Provider Business Practice Location Address
First Line	:	1054 GATEWAY BLVD
Second Line	:	SUITE 103
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8301
Country	:	US
Telephone Number	:	561-847-4654
Fax Number	:	561-847-4956

Authorized Official
Title or Position	:	OWNER/MANAGING PARTNER
Name	:	MR. KARL E VAETH
Credential	:
Telephone Number	:	561-225-9922

Provider Enumeration Date	:	02/24/2016
Last Update Date	:	02/24/2016

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Directions to “PURE AGE MANAGEMENT LLC ” Practice Location

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