Healthcare Provider Details

I. General information

NPI: 1164148763
Provider Name (Legal Business Name): CHRISTOPHER J CORDOVA HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 TAMIAMI TRL
PORT CHARLOTTE FL
33948-1042
US

IV. Provider business mailing address

23988 US HIGHWAY 19 N
CLEARWATER FL
33765-1563
US

V. Phone/Fax

Practice location:
  • Phone: 941-623-4918
  • Fax:
Mailing address:
  • Phone: 727-441-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5670
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: