Healthcare Provider Details

I. General information

NPI: 1154577021
Provider Name (Legal Business Name): SUNDARI PLASTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 FIVAY RD SUITE 130
HUDSON FL
34667-7180
US

IV. Provider business mailing address

PO BOX 5441
HUDSON FL
34674-5441
US

V. Phone/Fax

Practice location:
  • Phone: 727-378-5808
  • Fax: 727-378-5810
Mailing address:
  • Phone: 727-378-5808
  • Fax: 727-378-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS9566
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberOS9566
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN BARRY ROACH JR.
Title or Position: PRESIDENT
Credential: D.O.
Phone: 727-378-5808