Provider Demographics
NPI:1225671118
Name:PURE LIFE RENAL OF MIRAMAR, LLC
Entity Type:Organization
Organization Name:PURE LIFE RENAL OF MIRAMAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-962-5734
Mailing Address - Street 1:4000 HOLLYWOOD BLVD STE 300N
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-1242
Mailing Address - Country:US
Mailing Address - Phone:330-230-2667
Mailing Address - Fax:
Practice Address - Street 1:3180 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-3005
Practice Address - Country:US
Practice Address - Phone:954-962-5734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment