Provider Demographics
NPI:1932540036
Name:PURE EXECUTIVE HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:PURE EXECUTIVE HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-227-6811
Mailing Address - Street 1:11921 S DIXIE HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-4449
Mailing Address - Country:US
Mailing Address - Phone:786-227-6811
Mailing Address - Fax:786-732-2377
Practice Address - Street 1:11921 S DIXIE HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-4449
Practice Address - Country:US
Practice Address - Phone:786-227-6811
Practice Address - Fax:786-732-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty