Healthcare Provider Details

I. General information

NPI: 1427921139
Provider Name (Legal Business Name): KEVIN MAYORGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 CREWS LAKE DR
LAKELAND FL
33813-3916
US

IV. Provider business mailing address

3916 CREWS LAKE DR
LAKELAND FL
33813-3916
US

V. Phone/Fax

Practice location:
  • Phone: 863-521-5638
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9511570
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: