Healthcare Provider Details

I. General information

NPI: 1831651967
Provider Name (Legal Business Name): SUGAR 10 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 S ORLANDO AVE STE 306
MAITLAND FL
32751-5669
US

IV. Provider business mailing address

541 S ORLANDO AVE STE 306
MAITLAND FL
32751-5669
US

V. Phone/Fax

Practice location:
  • Phone: 407-529-4257
  • Fax:
Mailing address:
  • Phone: 407-529-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: HIEP Q LE
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 407-529-4257