Healthcare Provider Details

I. General information

NPI: 1245788595
Provider Name (Legal Business Name): BANANA WIND MEDICAL GROUP, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11335 COMMERCIAL ST
ORLANDO FL
32836-6216
US

IV. Provider business mailing address

35 W PINE ST SUITE 218
ORLANDO FL
32801-2610
US

V. Phone/Fax

Practice location:
  • Phone: 407-259-8731
  • Fax:
Mailing address:
  • Phone: 407-259-8731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberRN9246384
License Number StateFL

VIII. Authorized Official

Name: MR. ERIC LEE SHAVER
Title or Position: DIRECTOR OF NURSING
Credential: R.N.
Phone: 321-315-3601