Healthcare Provider Details

I. General information

NPI: 1730529488
Provider Name (Legal Business Name): VENEZIA,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 SLEEPY HILL RD
LAKELAND FL
33810-3800
US

IV. Provider business mailing address

1625 VILLAGE CENTER DR APT 203
LAKELAND FL
33803-2868
US

V. Phone/Fax

Practice location:
  • Phone: 863-858-4402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME103560
License Number StateFL

VIII. Authorized Official

Name: NICKOLAS SOUMELIDIS
Title or Position: FAMILY MEDICINE
Credential: MD
Phone: 301-401-8051