Provider Demographics
NPI:1629698121
Name:AMAVIE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:AMAVIE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAHOMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,AAPRN,FNP-BC
Authorized Official - Phone:786-285-9682
Mailing Address - Street 1:1492 NW 153RD AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2453
Mailing Address - Country:US
Mailing Address - Phone:786-285-9682
Mailing Address - Fax:
Practice Address - Street 1:1492 NW 153RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-2453
Practice Address - Country:US
Practice Address - Phone:786-285-9682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty