Healthcare Provider Details

I. General information

NPI: 1669027231
Provider Name (Legal Business Name): PHRC ORLANDO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 N HESPERIDES ST
TAMPA FL
33614-5414
US

IV. Provider business mailing address

5510 N HESPERIDES ST
TAMPA FL
33614-5414
US

V. Phone/Fax

Practice location:
  • Phone: 813-462-2588
  • Fax:
Mailing address:
  • Phone: 813-462-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSH MAYWALT
Title or Position: BILLING MANAGER
Credential:
Phone: 813-462-2588