1679974182 NPI number — PARADISE WELLNESS MEDICAL CENTER CORP

Table of content: (NPI 1679974182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679974182 NPI number — PARADISE WELLNESS MEDICAL CENTER CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARADISE WELLNESS MEDICAL CENTER CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679974182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4355 W 16TH AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIALEAH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33012-7667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-631-3763
Provider Business Mailing Address Fax Number:
786-631-3836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4355 W 16TH AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33012-7667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-631-3763
Provider Business Practice Location Address Fax Number:
786-631-3836
Provider Enumeration Date:
09/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
QUERAL
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
786-631-3763

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  ME118298 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com