Healthcare Provider Details

I. General information

NPI: 1336837665
Provider Name (Legal Business Name): PHOENIX HEALTH ASCENDENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17011 STATE ROAD 50 STE 103
CLERMONT FL
34711-8203
US

IV. Provider business mailing address

17011 STATE ROAD 50 STE 103
CLERMONT FL
34711-8203
US

V. Phone/Fax

Practice location:
  • Phone: 323-695-3822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER DIAZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 323-695-3822