Provider Demographics
NPI:1679974182
Name:PARADISE WELLNESS MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:PARADISE WELLNESS MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUERAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-631-3763
Mailing Address - Street 1:4355 W 16TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7667
Mailing Address - Country:US
Mailing Address - Phone:786-631-3763
Mailing Address - Fax:786-631-3836
Practice Address - Street 1:4355 W 16TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7667
Practice Address - Country:US
Practice Address - Phone:786-631-3763
Practice Address - Fax:786-631-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118298261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service