Healthcare Provider Details

I. General information

NPI: 1275166563
Provider Name (Legal Business Name): MASAGANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2020
Last Update Date: 02/15/2020
Certification Date: 02/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 N 16TH ST
TAMPA FL
33612-8655
US

IV. Provider business mailing address

10144 ARBOR RUN DR UNIT 28
TAMPA FL
33647-3568
US

V. Phone/Fax

Practice location:
  • Phone: 813-526-4155
  • Fax: 813-501-4995
Mailing address:
  • Phone: 813-526-4155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NEVEH C MAHILUM
Title or Position: MANAGER
Credential:
Phone: 813-526-4155