Healthcare Provider Details

I. General information

NPI: 1417544602
Provider Name (Legal Business Name): PRECISION CANCER CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14502 N DALE MABRY HWY STE 200
TAMPA FL
33618-2040
US

IV. Provider business mailing address

14502 N DALE MABRY HWY STE 200
TAMPA FL
33618-2040
US

V. Phone/Fax

Practice location:
  • Phone: 813-575-6880
  • Fax: 813-969-0910
Mailing address:
  • Phone: 813-575-6880
  • Fax: 813-969-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JODY SIMON
Title or Position: MANAGER
Credential:
Phone: 813-969-1722