Healthcare Provider Details

I. General information

NPI: 1669710141
Provider Name (Legal Business Name): FLORIDA HEART & VASCULAR CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CYPRESS EDGE DR SUITE 203
PALM COAST FL
32164-8453
US

IV. Provider business mailing address

146 PALM COAST RESORT BLVD SUITE 806
PALM COAST FL
32137-1812
US

V. Phone/Fax

Practice location:
  • Phone: 386-586-4410
  • Fax:
Mailing address:
  • Phone: 615-400-0380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KAREN CHRISTIANE THEILADE
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 386-237-7353