Healthcare Provider Details

I. General information

NPI: 1942949086
Provider Name (Legal Business Name): MEDICAL SPA AND PRIMARY CARE OF OCALA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 SW 1ST AVE
OCALA FL
34471-8167
US

IV. Provider business mailing address

1813 SW 1ST AVE
OCALA FL
34471-8167
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-7188
  • Fax: 352-355-2132
Mailing address:
  • Phone: 352-732-7188
  • Fax: 352-355-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BURGOS
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 352-732-9888