Healthcare Provider Details

I. General information

NPI: 1033528039
Provider Name (Legal Business Name): CIRQUE OF TOWERS INPATIENT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8341
  • Fax:
Mailing address:
  • Phone:
  • Fax: 214-712-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132