Healthcare Provider Details

I. General information

NPI: 1821372129
Provider Name (Legal Business Name): CYPRESS CREEK MEDICAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 HIGHLAND OAKS BLVD SUITE A
LUTZ FL
33559-7410
US

IV. Provider business mailing address

26827 FOGGY CREEK RD SUITE 101A
WESLEY CHAPEL FL
33544-6768
US

V. Phone/Fax

Practice location:
  • Phone: 813-948-3838
  • Fax: 813-949-0629
Mailing address:
  • Phone: 813-973-7774
  • Fax: 813-973-8882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0048283
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0040424
License Number StateFL

VIII. Authorized Official

Name: MRS. LINDA ROSEQUIST
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 813-948-3838