Provider Demographics
NPI:1609680776
Name:ACTIVA MEDICAL CENTER & SPA
Entity type:Organization
Organization Name:ACTIVA MEDICAL CENTER & SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-317-9247
Mailing Address - Street 1:11090 SW 64TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2028
Mailing Address - Country:US
Mailing Address - Phone:786-317-9247
Mailing Address - Fax:
Practice Address - Street 1:12966 SW 150TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7601
Practice Address - Country:US
Practice Address - Phone:786-406-2497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty