Healthcare Provider Details

I. General information

NPI: 1417021114
Provider Name (Legal Business Name): KOPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/22/2023
Certification Date: 10/02/2023
Deactivation Date: 12/15/2023
Reactivation Date: 12/22/2023

III. Provider practice location address

5900 LAKE ELLENOR DR STE 700
ORLANDO FL
32809-4643
US

IV. Provider business mailing address

5900 LAKE ELLENOR DR STE 700
ORLANDO FL
32809-4643
US

V. Phone/Fax

Practice location:
  • Phone: 407-352-2542
  • Fax: 844-556-8650
Mailing address:
  • Phone: 407-352-2542
  • Fax: 844-556-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY L BIEGASIEWICZ
Title or Position: PRESIDENT
Credential:
Phone: 407-216-0101