Healthcare Provider Details

I. General information

NPI: 1033956156
Provider Name (Legal Business Name): RUPALA GHANSHYAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 VENTURI CT
MELBOURNE FL
32940-1797
US

IV. Provider business mailing address

828 VENTURI CT
MELBOURNE FL
32940-1797
US

V. Phone/Fax

Practice location:
  • Phone: 321-364-2080
  • Fax:
Mailing address:
  • Phone: 321-364-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: STAN MYERS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 332-330-3903