Provider Demographics
NPI:1316912975
Name:LONG LIFE MEDICAL INC
Entity type:Organization
Organization Name:LONG LIFE MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAXEDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-552-7723
Mailing Address - Street 1:2780 SW 87 AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165
Mailing Address - Country:US
Mailing Address - Phone:305-552-7723
Mailing Address - Fax:305-552-7791
Practice Address - Street 1:2780 SW 87TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3296
Practice Address - Country:US
Practice Address - Phone:305-552-7723
Practice Address - Fax:305-552-7791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMCC4499261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
34637OtherBCBSF
34637OtherBCBSF