Healthcare Provider Details

I. General information

NPI: 1700553633
Provider Name (Legal Business Name): MYRTLE RIDGE PRIMARY CARE, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 DALE MABRY HWY STE 102
LUTZ FL
33548-3008
US

IV. Provider business mailing address

1539 DALE MABRY HWY STE 102
LUTZ FL
33548-3008
US

V. Phone/Fax

Practice location:
  • Phone: 813-909-7102
  • Fax: 813-909-0199
Mailing address:
  • Phone: 813-909-7102
  • Fax: 813-909-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YUDAISY MOGENA
Title or Position: OFFICE MANAGER
Credential:
Phone: 813-909-7102