Provider Demographics
NPI:1043900798
Name:JUVENSA LLC
Entity Type:Organization
Organization Name:JUVENSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNEYD
Authorized Official - Middle Name:
Authorized Official - Last Name:AVALOS PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-925-3143
Mailing Address - Street 1:9803 SW 134TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2265
Mailing Address - Country:US
Mailing Address - Phone:786-925-3143
Mailing Address - Fax:305-468-6217
Practice Address - Street 1:2500 NW 79TH AVE STE 265
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1088
Practice Address - Country:US
Practice Address - Phone:786-504-4626
Practice Address - Fax:305-468-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-08
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty