Healthcare Provider Details

I. General information

NPI: 1255654554
Provider Name (Legal Business Name): HAI YANG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6838 HUNTINGTON HILLS BLVD
LAKELAND FL
33810-5378
US

IV. Provider business mailing address

6838 HUNTINGTON HILLS BLVD
LAKELAND FL
33810-5378
US

V. Phone/Fax

Practice location:
  • Phone: 863-899-3621
  • Fax:
Mailing address:
  • Phone: 863-899-3621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT12589
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: