Provider Demographics
NPI:1336656495
Name:PROLIVE MEDICAL RESEARCH CORP
Entity Type:Organization
Organization Name:PROLIVE MEDICAL RESEARCH CORP
Other - Org Name:PROLIVE MEDICAL RESEARCH CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-221-8001
Mailing Address - Street 1:12781 SW 42ND ST STE I
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3437
Mailing Address - Country:US
Mailing Address - Phone:305-221-8001
Mailing Address - Fax:
Practice Address - Street 1:12781 SW 42ND ST STE I
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3437
Practice Address - Country:US
Practice Address - Phone:305-221-8001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherCLINICAL RESEARCH