Healthcare Provider Details

I. General information

NPI: 1659604122
Provider Name (Legal Business Name): DIABETES WELLNESS CLINICS OF TAMPA BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 TAMPA RD
OLDSMAR FL
34677-3104
US

IV. Provider business mailing address

3941 TAMPA RD
OLDSMAR FL
34677-3104
US

V. Phone/Fax

Practice location:
  • Phone: 813-448-1055
  • Fax: 813-448-1057
Mailing address:
  • Phone: 813-448-1055
  • Fax: 813-448-1057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD HENRY DORSEY
Title or Position: PRESIDENT
Credential:
Phone: 813-448-1055