Provider Demographics
NPI:1083216022
Name:ETERNITY MEDICAL GROUP CORP
Entity Type:Organization
Organization Name:ETERNITY MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-332-3136
Mailing Address - Street 1:900 SW 8TH ST STE C1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3756
Mailing Address - Country:US
Mailing Address - Phone:786-332-3136
Mailing Address - Fax:305-726-0013
Practice Address - Street 1:900 SW 8TH ST STE C1
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3756
Practice Address - Country:US
Practice Address - Phone:786-332-3136
Practice Address - Fax:305-726-0013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13052OtherHEALTH CARE CLINIC STANDARD LICENSE
FL108835400Medicaid