Healthcare Provider Details

I. General information

NPI: 1518260090
Provider Name (Legal Business Name): ST. JUDE MEDICAL & AESTHETIC CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N MOON AVE SUITES 3 & 4
BRANDON FL
33510-4418
US

IV. Provider business mailing address

4810 PORTOBELLO CIR
VALRICO FL
33596
US

V. Phone/Fax

Practice location:
  • Phone: 813-315-9898
  • Fax: 813-438-5967
Mailing address:
  • Phone: 813-315-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License NumberME107980
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME107980
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME107980
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME107980
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberME107980
License Number StateFL

VIII. Authorized Official

Name: DR. GODWIN STANLEY OKOYE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 813-330-6613