Provider Demographics
NPI:1659088052
Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Entity Type:Organization
Organization Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-507-8556
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:2020 NE 48TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4522
Practice Address - Country:US
Practice Address - Phone:954-637-1168
Practice Address - Fax:954-568-1330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty