Provider Demographics
NPI:1790376887
Name:GREAT LIFE MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:GREAT LIFE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIGIL PEREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-857-4952
Mailing Address - Street 1:4355 W 16TH AVE STE 205B
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7668
Mailing Address - Country:US
Mailing Address - Phone:786-353-2732
Mailing Address - Fax:
Practice Address - Street 1:4355 W 16TH AVE STE 205B
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7668
Practice Address - Country:US
Practice Address - Phone:786-353-2732
Practice Address - Fax:786-353-2739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health