Provider Demographics
NPI:1811357122
Name:NIRVANA CLINIC CENTER LLC
Entity type:Organization
Organization Name:NIRVANA CLINIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-577-0024
Mailing Address - Street 1:8765 SW 165TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-5832
Mailing Address - Country:US
Mailing Address - Phone:786-577-0024
Mailing Address - Fax:786-773-2234
Practice Address - Street 1:8765 SW 165TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5832
Practice Address - Country:US
Practice Address - Phone:786-577-0024
Practice Address - Fax:786-773-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase Management