Healthcare Provider Details

I. General information

NPI: 1053034298
Provider Name (Legal Business Name): HEAVEN WELLNESS MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11961 N FLORIDA AVE STE B
TAMPA FL
33612-5213
US

IV. Provider business mailing address

PO BOX 15542
TAMPA FL
33684-5542
US

V. Phone/Fax

Practice location:
  • Phone: 813-415-2891
  • Fax: 813-443-3149
Mailing address:
  • Phone: 813-415-2891
  • Fax: 813-443-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LAZARA HURTADO HERNANDEZ
Title or Position: OWNER
Credential:
Phone: 813-409-9457