Healthcare Provider Details

I. General information

NPI: 1306559265
Provider Name (Legal Business Name): EXCELLENCE HEALTH SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 MASON AVE STE C
DAYTONA BEACH FL
32117-4503
US

IV. Provider business mailing address

1630 MASON AVE STE C
DAYTONA BEACH FL
32117-4503
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-9064
  • Fax: 386-238-9063
Mailing address:
  • Phone: 386-238-9064
  • Fax: 386-238-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: HUSAM EDDIN
Title or Position: CEO
Credential: MD
Phone: 386-238-9064