Healthcare Provider Details

I. General information

NPI: 1992302574
Provider Name (Legal Business Name): AVITA MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14831 N FLORIDA AVE
TAMPA FL
33613-1825
US

IV. Provider business mailing address

14831 N FLORIDA AVE
TAMPA FL
33613-1825
US

V. Phone/Fax

Practice location:
  • Phone: 813-330-2737
  • Fax: 813-210-9205
Mailing address:
  • Phone: 813-210-0982
  • Fax: 813-210-9205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNY M SEGARRA
Title or Position: PRESIDENT
Credential:
Phone: 813-330-2737