Healthcare Provider Details

I. General information

NPI: 1134943657
Provider Name (Legal Business Name): TAMPA FAMILY SPECIALTY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W MLK BLVD STE 100A
TAMPA FL
33607-6353
US

IV. Provider business mailing address

2727 W MLK BLVD STE 100A
TAMPA FL
33607-6353
US

V. Phone/Fax

Practice location:
  • Phone: 813-397-5300
  • Fax:
Mailing address:
  • Phone: 813-397-5300
  • 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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHELSEY L BIBEAU
Title or Position: PROJECT DIRECTOR
Credential:
Phone: 720-308-0650