Healthcare Provider Details

I. General information

NPI: 1881782332
Provider Name (Legal Business Name): KURT PHILLIP MICKELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 RESCUE WAY
CLEARWATER FL
33762
US

IV. Provider business mailing address

155 LARGS CT # 2-207
DUNEDIN FL
34698-8387
US

V. Phone/Fax

Practice location:
  • Phone: 727-535-1437
  • Fax: 727-535-4190
Mailing address:
  • Phone: 808-375-9232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: