Provider Demographics
NPI:1669832341
Name:PURE AGE MANAGEMENT LLC
Entity Type:Organization
Organization Name:PURE AGE MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-225-9922
Mailing Address - Street 1:1054 GATEWAY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8301
Mailing Address - Country:US
Mailing Address - Phone:561-847-4654
Mailing Address - Fax:561-847-4956
Practice Address - Street 1:1054 GATEWAY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8301
Practice Address - Country:US
Practice Address - Phone:561-847-4654
Practice Address - Fax:561-847-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83769207R00000X, 207RI0001X, 2083B0002X, 2083T0002X
FL10D2100646291U00000X
FLPA9106969363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty
No2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical ToxicologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty