Healthcare Provider Details

I. General information

NPI: 1093362386
Provider Name (Legal Business Name): ROSSITER & CUMMARO ENTERPRIZE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 FITZGERALD RD STE 1
LAKELAND FL
33813-2633
US

IV. Provider business mailing address

170 FITZGERALD RD STE 1
LAKELAND FL
33813-2633
US

V. Phone/Fax

Practice location:
  • Phone: 813-754-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. KELLY KING
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 813-244-4741