Healthcare Provider Details

I. General information

NPI: 1225087430
Provider Name (Legal Business Name): DWIC OF TAMPA BAY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22945 STATE ROAD 54
LUTZ FL
33549-6932
US

IV. Provider business mailing address

423 FORTRESS BLVD
MORGANTOWN WV
26508-1351
US

V. Phone/Fax

Practice location:
  • Phone: 813-909-9099
  • Fax: 813-909-1822
Mailing address:
  • Phone: 304-225-2500
  • Fax: 304-985-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOY KIMBALL
Title or Position: CONTRACT MANAGER
Credential:
Phone: 763-349-6740