Healthcare Provider Details

I. General information

NPI: 1649093097
Provider Name (Legal Business Name): ATLANTIC COVE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22141 VENTURA BLVD STE 300
WOODLAND HILLS CA
91364-5734
US

IV. Provider business mailing address

5342 CLARK RD # 3072
SARASOTA FL
34233-3227
US

V. Phone/Fax

Practice location:
  • Phone: 941-208-3070
  • Fax: 941-208-3070
Mailing address:
  • Phone: 941-208-3070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: COLLINS EZEUKA
Title or Position: CEO, CMO, FOUNDER
Credential: MD
Phone: 941-208-3070