Healthcare Provider Details

I. General information

NPI: 1457709503
Provider Name (Legal Business Name): DAVENPORT ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date: 06/30/2021
Reactivation Date: 07/09/2021

III. Provider practice location address

107 PARK PLACE BLVD
DAVENPORT FL
33837-6858
US

IV. Provider business mailing address

107 PARK PLACE BLVD
DAVENPORT FL
33837-6858
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-2812
  • Fax: 863-419-2821
Mailing address:
  • Phone: 863-419-2812
  • Fax: 863-419-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: NANCY K KASTNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-256-0933