Healthcare Provider Details

I. General information

NPI: 1740559855
Provider Name (Legal Business Name): CARDIOLOGY PHYSICIANS MEMORIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 05/02/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MEMORIAL MEDICAL PKWY SUITE 200
DAYTONA BEACH FL
32117
US

IV. Provider business mailing address

103 MEMORIAL MEDICAL PKWY SUITE 200
DAYTONA BEACH FL
32117-5121
US

V. Phone/Fax

Practice location:
  • Phone: 386-615-1521
  • Fax: 386-671-0694
Mailing address:
  • Phone: 386-615-1521
  • Fax: 386-671-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: TRENAE HOSKIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 386-615-1521