Healthcare Provider Details

I. General information

NPI: 1083205231
Provider Name (Legal Business Name): INDEPENDENT MEDICAL GROUP, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2021
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S HOSPITAL DRIVE SUITE 2
PLANTATION FL
33317
US

IV. Provider business mailing address

4101 S HOSPITAL DRIVE SUITE 2
PLANTATION FL
33317
US

V. Phone/Fax

Practice location:
  • Phone: 407-314-7492
  • Fax: 833-253-4230
Mailing address:
  • Phone: 407-314-7492
  • Fax: 833-253-4230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SONIA N TORRES
Title or Position: CLINICAL OPERATIONS MANAGER
Credential:
Phone: 407-505-6435