Healthcare Provider Details

I. General information

NPI: 1508223140
Provider Name (Legal Business Name): ENVIZION MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 LETAP CT SUITE 101
LAND O LAKES FL
34638-7229
US

IV. Provider business mailing address

PO BOX 9830
SALT LAKE CITY UT
84109-9830
US

V. Phone/Fax

Practice location:
  • Phone: 813-279-2211
  • Fax: 813-948-3999
Mailing address:
  • Phone: 727-755-0693
  • Fax: 727-755-0679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberME67888
License Number StateFL

VIII. Authorized Official

Name: KATHLEEN VAES
Title or Position: OWNER
Credential:
Phone: 813-205-4550