Healthcare Provider Details

I. General information

NPI: 1124527957
Provider Name (Legal Business Name): ANNIE BETHEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 E SILVER STAR RD STE 514
OCOEE FL
34761-7014
US

IV. Provider business mailing address

1746 E SILVER STAR RD STE 514
OCOEE FL
34761-7014
US

V. Phone/Fax

Practice location:
  • Phone: 817-891-4688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN AGBONIFO
Title or Position: MANAGER
Credential:
Phone: 817-891-4688