Provider Demographics
NPI:1922523604
Name:PURA VIDA MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:PURA VIDA MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NURY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-874-3909
Mailing Address - Street 1:7925 NW 12TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1821
Mailing Address - Country:US
Mailing Address - Phone:305-874-3909
Mailing Address - Fax:
Practice Address - Street 1:1738 W 49TH ST STE 7-12
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3456
Practice Address - Country:US
Practice Address - Phone:305-698-8432
Practice Address - Fax:305-698-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty