Provider Demographics
NPI:1174816763
Name:MANANTIAL DE VIDA NUEVA INC
Entity Type:Organization
Organization Name:MANANTIAL DE VIDA NUEVA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIULIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-233-8055
Mailing Address - Street 1:13255 SW 137TH AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5326
Mailing Address - Country:US
Mailing Address - Phone:305-233-8055
Mailing Address - Fax:786-573-4677
Practice Address - Street 1:13255 SW 137TH AVE
Practice Address - Street 2:STE. 100
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5326
Practice Address - Country:US
Practice Address - Phone:305-233-8055
Practice Address - Fax:786-573-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8847261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center