Healthcare Provider Details

I. General information

NPI: 1386408706
Provider Name (Legal Business Name): BLUEROCK MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N RIDGEWOOD DR
SEBRING FL
33870-7217
US

IV. Provider business mailing address

505 SUMMIT DR
SEBRING FL
33870-2341
US

V. Phone/Fax

Practice location:
  • Phone: 863-873-0072
  • Fax:
Mailing address:
  • Phone: 863-873-0072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIE LECLAIR SPENCER
Title or Position: OWNER
Credential: DNP, APRN, FNP-C
Phone: 863-873-0072