Healthcare Provider Details

I. General information

NPI: 1053869487
Provider Name (Legal Business Name): MEDICAL VENTURES OF AMERICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16890 US HIGHWAY 441
MOUNT DORA FL
32757-6705
US

IV. Provider business mailing address

16890 US HIGHWAY 441
MOUNT DORA FL
32757-6705
US

V. Phone/Fax

Practice location:
  • Phone: 352-315-1651
  • Fax: 352-315-1703
Mailing address:
  • Phone: 352-315-1651
  • Fax: 352-315-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME77919
License Number StateFL

VIII. Authorized Official

Name: GLENDA MARTI
Title or Position: BILLING MANAGER
Credential:
Phone: 352-315-1651