Healthcare Provider Details

I. General information

NPI: 1497638241
Provider Name (Legal Business Name): MEDFAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 08/02/2025
Certification Date: 08/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4061 58TH AVENUE N LOT 325
PINELLAS PARK FL
33781
US

IV. Provider business mailing address

4061 58TH AVENUE N LOT 325
PINELLAS PARK FL
33781
US

V. Phone/Fax

Practice location:
  • Phone: 631-552-2859
  • Fax:
Mailing address:
  • Phone: 631-552-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: DANIEL JOSEPH SMOCER
Title or Position: AMBR
Credential:
Phone: 631-552-2859