MEDICARE: PURA VIDA MEDICAL CENTER, 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	261QP2300X	Primary Care Clinic/Center
2	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922523604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURA VIDA MEDICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	7925 NW 12TH ST STE 201
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33126-1821
Country	:	US
Telephone Number	:	305-874-3909
Fax Number	:

Provider Business Practice Location Address
First Line	:	1738 W 49TH ST STE 7-12
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3456
Country	:	US
Telephone Number	:	305-698-8432
Fax Number	:	305-698-8975

Authorized Official
Title or Position	:	OWNER
Name	:	NURY CARBAJAL
Credential	:
Telephone Number	:	305-874-3909

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	06/24/2020

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