Healthcare Provider Details

I. General information

NPI: 1699402131
Provider Name (Legal Business Name): TAMPA FAMILY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19203 N DALE MABRY HWY
LUTZ FL
33548-5067
US

IV. Provider business mailing address

PO BOX 82969
TAMPA FL
33682-2969
US

V. Phone/Fax

Practice location:
  • Phone: 813-397-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CREDENTIALING DEPT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 813-284-4554